OBJECTIVE: An opioid prescription after cesarean delivery confers an increased risk for new persistent opioid use to new mothers.1 To address this risk, many institutions have implemented opioid-sparing protocols, which leverage nonopioid medication (nonsteroidal anti-inflammatory medications and acetaminophen) and limited use of opioids.2,3 Although these protocols have successfully decreased inpatient opioid use and discharge prescription size, their effect on outpatient opioid consumption and recovery is unknown. We assessed opioid prescription, consumption, pain, and recovery in postcesarean delivery patients for whom an opioid-sparing protocol was implemented.
STUDY DESIGN: We performed an observational outcome study of patients >18 years who underwent a cesarean delivery at our institution from March 2019 to November 2019. Postdelivery, all patients were managed with opioid-sparing pain therapy, including scheduled nonopioid medications and limited oxycodone as needed during admission, and ≤20 tablets at discharge.2 In July 2019, opioid-sparing protocol enhancements were implemented, including patient education materials, provider training, and shared decision-making for determining prescription size (Appendix).
Patients were followed for 6 to 12 weeks after delivery to evaluated (1) postdischarge nonopioid and opioid pain medication use; (2) pain scores at discharge and 1 week postpartum; and (3) postpartum recovery, including if pain interfered with infant care and breastfeeding. Demographic and clinical variables were abstracted from the medical records and summarized using basic descriptive statistics. We compared differences in opioid prescribing, consumption, and pain management before and after protocol implementation. A logistic regression was used to evaluate the reported consumption of an opioid postpartum among the full cohort. A linear regression was used to evaluated the number of opioid tablets consumed among those who received a prescription. All models accounted for individual patient characteristics and the timing of the opioid-sparing protocol enhancement.
This survey-based study was deemed exempt by our institution's institutional review board, and participant consent was implied by survey continuation.
RESULTS: Of the 1161 patients contacted, 546 (47.2%) agreed to participate. The participants’ demographics are presented in Table 1. In brief, the majority were White (405; 74.2%) and commercially insured (419; 76.7%) with an average (standard deviation) age of 32.7 (5.1) years; 312 (57%) were managed with the opioid-sparing protocol with enhancements.
Table 1.
Demographics, clinical characteristics, and outcomes for patients who did and did not use postpartum opioids
| Variable | All patients (N=546) | Opioid-sparing protocol (n=234) | Opioid-sparing protocol with enhancements (n=312) | P value |
|---|---|---|---|---|
| Age (y)a | 32.7 (5.1) | 32.7 (5) | 32.7 (5.2) | .99 |
| Race | ||||
| White | 405 (74.2) | 160 (68.4) | 245 (78.5) | .03 |
| Black or African American | 73 (13.4) | 40 (17.1) | 33 (10.6) | |
| Asian | 39 (7.1) | 17 (7.3) | 22 (7.1) | |
| Other or unknown | 29 (5.3) | 17 (7.3) | 12 (3.9) | |
| Ethnicity | ||||
| Hispanic | 27 (5) | 11 (4.7) | 16 (5.1) | 1.00 |
| Non-Hispanic | 513 (94) | 220 (94) | 293 (93.9) | |
| Other or unknown | 6 (1.1) | 3 (1.3) | 3 (1) | |
| Payer | ||||
| Public | 92 (16.9) | 37 (15.8) | 55 (17.6) | .87 |
| Commercial | 419 (76.7) | 182 (77.8) | 237 (76) | |
| Unknown | 35 (6.4) | 15 (6.4) | 20 (6.4) | |
| Smoking status | ||||
| Current | 31 (5.7) | 8 (3.4) | 23 (7.4) | .14 |
| Former | 119 (21.8) | 51 (21.8) | 68 (21.8) | |
| Never | 396 (72.5) | 175 (74.8) | 221 (70.8) | |
| Paritya | 2.0 (1.2) | 1.9 (1.2) | 2.0 (1.2) | .36 |
| Cesarean delivery type | ||||
| Unplanned | 293 (53.7) | 124 (53) | 169 (54.2) | .80 |
| Planned | 253 (46.3) | 110 (47) | 143 (45.8) | |
| Anesthesia | ||||
| Regional (combined, spinal, epidural) | 496 (91) | 213 (91.4) | 283 (90.7) | .88 |
| General | 49 (9) | 20 (8.6) | 29 (9.3) | |
| Length of surgery (min)a | 62.9 (29.4) | 61.3 (24.4) | 64.2 (32.8) | .12 |
| Postpartum estimated blood loss (mL)a | 1029.6 (585.4) | 1057.6 (524.8) | 1008.3 (627.8) | .33 |
| Length of stay (d)a | 2.5 (0.8) | 2.6 (0.9) | 2.4 (0.8) | .25 |
| Opioid prescribing and use | ||||
| Patients prescribed a postdischarge opioid | 435 (79.7) | 190 (81.2) | 245 (78.5) | .45 |
| Patients who reported using an opioid among those with a discharge prescriptionb | 328 (76.1) | 139 (74.7) | 189 (77.1) | .57 |
| Opioid tablets prescribedc | 20 (10-20) | 20 (15-20) | 20 (10-20) | <.001 |
| Opioid tablets reportedly usedc | 5 (0.5-12) | 5 (0-10) | 5 (1-13) | .96 |
| Patients who refilled their prescriptiond | 29 (8.8) | 9 (6.5) | 20 (10.6) | .24 |
| Non-opioid use | ||||
| Acetaminophen and Ibuprofen (any) | 431 (78.9) | 171 (73.1) | 260 (83.3) | <.001 |
| Acetaminophen only (any) | 48 (8.8) | 33 (14.1) | 15 (4.8) | |
| Ibuprofen only (any) | 49 (9) | 22 (9.4) | 27 (8.7) | |
| No use of acetaminophen or ibuprofen | 18 (3.3) | 8 (3.4) | 10 (3.2) | |
| Pain score on 0–10 point scale | ||||
| In hospitalc | 5.7 (2.5) | 5.6 (2.5) | 5.8 (2.4) | .99 |
| One week postdischargec | 5.2 (2.4) | 5.2 (2.4) | 5.2 (2.3) | .44 |
| Perceived pain or side effectsb | ||||
| Pain controlled without opioid medicatione | 312 (58) | 139 (61.2) | 173 (55.6) | .22 |
| Reported side effect from opioid medicatione | 124 (37.9) | 59 (42.5) | 65 (34.6) | .15 |
| Time to 100% recovery (wk)c | 6 (4-8) | 6 (4-8) | 5 (3-6) | <.001 |
| Pain interfered with newborn caref | 277 (52) | 123 (54.2) | 154 (50.3) | .38 |
| Pain interfered with newborn bondingf | 118 (22.2) | 48 (21.2) | 70 (22.9) | .67 |
| Pain interfered with breastfeedingf | 143 (30) | 70 (33.5) | 73 (27.3) | .16 |
Data presented as number (percentage) unless otherwise noted.
Data are presented as mean (standard deviation)
The data for n=431 are presented
The data are presented as median (interquartile range)
Among those who reported consuming the tablets obtained from a prescription
All patients surveyed (n=546)
Score of 3–5 on a 5-point pain scale.
Peahl. Recovering following cesarean delivery with an opiod-sparing pain regiment. Am J Obstet Gynecol Glob Rep 2023.
Post discharge, the majority of patients were provided with (435; 79.7%) and used (328; 76.1%) an opioid prescription. The median prescription size was 20 tablets (interquartile range [IQR], 10–20) and the median number of tablets consumed was 5 (IQR, 0.5–12). Most patients used nonopioid medication to control their pain (528; 96.7%). Postimplementation of the protocol enhancement, the prescription size and number of tablets consumed remained the same, but the IQR broadened from 15–20 to 10–20; the refill rates were higher, but the difference was not statistically significant (10.6% vs 6.5%; P=.24), and the median time to recovery was 1 week shorter (6; IQR, 4–8 vs 5; IQR, 3–6; P<.01). Many patients reported that pain affected their ability to care for their newborn (277; 52%), to bond with their newborn (118; 22.2%), and to breastfeed (143; 30.0%).
In the adjusted models (Table 2), participant characteristics associated with a lower likelihood of opioid consumption were low pain scores (<4/10) on the day of discharge (adjusted odds ratio [aOR], 0.27; 95% confidence interval [CI], 0.18–0.42) and unplanned cesarean delivery (aOR, 0.65; 95% CI, 0.43–0.99). Characteristics associated with a higher likelihood of opioid consumption included a procedure >1 hour (1–2 hours: aOR, 1.60; 95% CI, 1.06–2.42; ≥2 hours: 4.50; 95% CI, 1.26–16.12) and use of any opioid-sparing medications (aOR, 5.72; 95% CI, 1.73–18.93). Factors associated with the consumption of more opioid tablets included childbirth after implementation of the protocol enhancement (estimate, 1.91; 95% CI, 0.29–3.52), current smoking (estimate, 4.65; 95% CI, 1.00–8.30), and more tablets prescribed (estimate, 0.63; 95% CI, 0.49–0.76). Patients who consumed fewer opioid tablets were older (estimate, −0.18; 95% CI, −0.35 to 0.02).
Table 2.
Predictors of opioid tabs consumed, among patients with a validated prescription
| Variable | Estimate | 95% CI | P value |
|---|---|---|---|
| Opioid-sparing protocol with enhancements | 1.91 | 0.29–3.52 | .02 |
| Opioid tablets prescribed | 0.63 | 0.49–0.76 | <.001 |
| Pain controlled (<4 on 0–10 point scale) | −1.89 | −3.90 to 0.12 | .07 |
| Age (y), continuous | −0.18 | −0.35 to −0.02 | .03 |
| Race | |||
| White | Ref | ||
| Black | −0.26 | −2.59 to 2.08 | .83 |
| Asian | −1.34 | −4.46 to 1.78 | .40 |
| Other or unknown | −1.54 | −5.80 to 2.71 | .48 |
| Ethnicity | |||
| Non-Hispanic | Ref | ||
| Hispanic | 0.83 | −3.33 to 4.99 | .69 |
| Unknown | −1.93 | −9.66 to 5.80 | .62 |
| Payer | |||
| Commercial | Ref | ||
| Public | 0.11 | −2.17 to 2.39 | .93 |
| Unknown | −2.29 | −5.47 to 0.89 | .16 |
| Smoking status | |||
| Never | Ref | ||
| Current | 4.65 | 1.00–8.30 | .01 |
| Former | 0.03 | −1.91 to 1.97 | .97 |
| Parity | 0.57 | −0.24 to 1.38 | .17 |
| Length of stay (d) | 0.36 | −0.61 to 1.33 | .47 |
| General anesthesia | 0.71 | −2.34 to 3.76 | .65 |
| Estimated blood loss (mL) | |||
| <1000 | Ref | ||
| ≥1000 | −0.01 | −1.69 to 1.67 | .99 |
| Unknown | −1.92 | −5.63 to 1.78 | .31 |
| Procedure duration | |||
| <1 h | Ref | ||
| 1–2 h | 0.79 | −0.93 to 2.52 | .37 |
| ≥2 h | −0.05 | −4.49 to 4.39 | .98 |
| Unknown | −1.39 | −5.41 to 2.63 | .50 |
| Unplanned cesarean delivery | 0.57 | −1.22 to 2.36 | .53 |
| Non-opioid pain management (ref=None) | |||
| Ibuprofen only, any | 0.83 | −5.50 to 7.17 | .80 |
| Acetaminophen only, any | 1.54 | −4.86 to 7.93 | .64 |
| Acetaminophen and Ibuprofen, any | 0.81 | −5.09 to 6.71 | .79 |
The data for n=417a are presented.
CI, confidence interval.
aAround 18 participants were excluded from the analysis because of missing data.
Peahl. Recovering following cesarean delivery with an opiod-sparing pain regiment. Am J Obstet Gynecol Glob Rep 2023.
Peahl. Recovering following cesarean delivery with an opiod-sparing pain regiment. Am J Obstet Gynecol Glob Rep 2023.
CONCLUSION: The median number of 5 mg tablets of oxycodone consumed by patients who were managed with an opioid-sparing protocol after cesarean birth was 5—a quarter of the postdischarge consumption previously reported in the literature.4,5 Opioid prescribing and consumption were already low when protocol enhancements were implemented, suggesting limited opportunity for protocol changes to reduce the overall prescribing rates. Still, our results suggest that there was improved prescription tailoring on the basis of the wider range of prescription sizes. Even with opioid-sparing protocols, many patients reported that pain interfered with parenting activities. Future work is needed to best support the unique challenges faced by postpartum patients recovering from surgery who must balance the risks of opioid medications with the demands of parenthood.
Footnotes
This study was funded by the National Institute on Drug Abuse under grant number R01DA042859 to C.M.B. and J.F.W., by the Substance Abuse and Mental Health Services Administration under grant number E20203206-00, and by Medicaid under grant number E20203374-00. The funders played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.
C.M.B. reports serving as a consultant for Heron Therapeutics (San Diego, CA). A.F.P. reports serving as a paid consultant for Maven Clinic. The remaining authors report no conflict of interest.
Supplementary material associated with this article can be found in the online version at doi:10.1016/j.xagr.2023.100248.
Appendix. Supplementary materials
References
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