Multimodal Stepwise Approach to Reducing In-Hospital Opioid Use After Cesarean Delivery

Abstract

OBJECTIVE: To evaluate the association of a standardized, structured approach to in-hospital postcesarean delivery pain management with maternal opioid use after cesarean delivery. METHODS: We conducted a retrospective cohort study of women who underwent cesarean delivery before and after a quality improvement intervention at a single tertiary care center. A multidisciplinary task force revised electronic order sets for all patients who underwent cesarean delivery with neuraxial anesthesia. The revised order set separated acetaminophen from opioids, scheduled acetaminophen and nonsteroidal antiinflammatory drug administration, and limited opioid use to breakthrough pain. Data were collected by electronic chart review. The primary outcome was median morphine milligram equivalents per hospital stay. Secondary outcomes included median morphine milligram equivalents per day, median pain scores, time to discharge, and opioid–nonopioid pain medication use. Descriptive and bivariable analyses were performed. RESULTS: There were no significant differences in baseline characteristics in the preintervention (n=283) and postintervention (n=286) groups. There was a 75% reduction in median morphine milligram equivalents per stay from 120 (90–176 interquartile range) preintervention to 30 (5–68) postintervention (P<.001) and a 77% reduction in median morphine milligram equivalents per day (51 [41–60] vs 12 [2–25], P<.001). There was no difference between groups in time to discharge or median pain scores. There was no difference in ketorolac use (80% preintervention vs 75% postintervention, P=.14) or in median ibuprofen mg per day (1,391 preintervention vs 1,347 postintervention, P=.22). There was an increase in median acetaminophen mg per day (753 preintervention vs 2,340 postintervention, P<.001). There was a significant increase in patients who used no opioids during their hospital stay (6% preintervention vs 19% postintervention, P<.001). CONCLUSION: A multimodal stepwise approach to postcesarean delivery pain control was associated with markedly reduced opioid consumption without increasing hospital stay or median pain scores. By separating acetaminophen from opioids and limiting opioids to breakthrough pain, we were able to operationalize a tier-based approach to pain management.

Rates of New Persistent Opioid Use After Vaginal or Cesarean Birth Among US Women

“…16,26 Opioid-sparing pain protocols for cesarean delivery have been shown to successfully decrease opioid prescribing while maintaining patient comfort. 27,28 These protocols include 3 main components: patient preparation (when cesarean delivery is scheduled), perioperative measures, and multimodal postoperative therapy. Preparation can help patients set expectations and develop coping techniques prior to surgery.…”

“…30,31 Similarly, using scheduled nonnarcotic medications, such as acetaminophen and ketorolac or ibuprofen, has been shown to reduce the total OME requirement per patient. 27,28 Enhanced Recovery After Surgery protocols for obstetrics have the potential to coordinate pain management across the delivery episode through standardized protocols. 30,31,32 However, there is a lack of data on appropriate pain management techniques following vaginal delivery, and more work is needed to understand the role of opioids and opioid-sparing pain protocols for both vaginal delivery and cesarean delivery.…”

https://doi.org/10.46409/sr.FIKZ6752

“…One highquality retrospective cohort study saw a substantial reduction in opioids as COX-2 inhibitors and NSAIDs were administered (Cozowics et al, 2019). Contrastingly, another good quality retrospective cohort study found that as acetaminophen use per day increased in combination with NSAID administration, the primary outcome of median morphine milligram equivalents administered reduced (Smith et al, 2019).…”

“…Several studies support the use of non-opioid analgesics (acetaminophen, NSAIDs, COX-2 inhibitors, and gabapentin/pregabalin) both preoperatively and postoperatively to improve pain management (Cozowics et al, 2019, Smith, Young, Blosser, & Poole, 2019Desai et al, 2018;Militsakh et al, 2018;Brandal et al, 2017;Brubaker, Kendall, & Reina, 2016). One highquality retrospective cohort study saw a substantial reduction in opioids as COX-2 inhibitors and NSAIDs were administered (Cozowics et al, 2019).…”

“…Integrating non-opioid approaches in the hospital can reduce the administration of opioids (Smith et al, 2019), thereby reducing exposure and exploitation of high-risk drugs.…”