Predictors of patient post-discharge opioid use after cesarean delivery: a prospective study

Cohen, Alexa; Xie, Xianhong; Zeuner, R.; Galperin, Sharon; Bruney, Talitha

doi:10.1016/j.ijoa.2021.103249

Cited by 3 publications

(3 citation statements)

References 7 publications

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“…14,30 Most individuals with cesarean births in the United States are discharged home with opioid prescriptions. 31–33 Our fixed quantity of 20 tablets was similar to the median number of opioids tablets prescribed for postcesarean outpatient pain management during the coronavirus disease 2019 (COVID-19) pandemic (after March 2022), 33 suggesting external generalizability. In addition to not compromising pain management, the IOPP with shared decision making intervention significantly decreased the number of unused tablets, which has both individual- and population-level implications.…”

Section: Discussionmentioning

confidence: 68%

Optimizing Opioid Prescription Quantity After Cesarean Delivery

Smid,

Clifton,

Rood

et al. 2024

Obstetrics &Amp; Gynecology

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OBJECTIVE: To test whether an individualized opioid-prescription protocol (IOPP) with a shared decision-making component can be used without compromising postcesarean pain management. METHODS: In this multicenter randomized controlled noninferiority trial, we compared IOPP with shared decision making with a fixed quantity of opioid tablets at hospital discharge. We recruited at 31 centers participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Study participants had uncomplicated cesarean births. Follow-up occurred through 12 weeks postdischarge. Individuals with complicated cesarean births or history of opioid use in the pregnancy were excluded. Participants were randomized 1:1 to IOPP with shared decision making or fixed quantity (20 tablets of 5 mg oxycodone). In the IOPP group, we calculated recommended tablet quantity based on opioid use in the 24 hours before discharge. After an educational module and shared decision making, participants selected a quantity of discharge tablets (up to 20). The primary outcome was moderate to severe pain (score 4 or higher [possible range 0–10]) on the BPI (Brief Pain Inventory) at 1 week after discharge. A total sample size of 5,500 participants was planned to assess whether IOPP with shared decision making was not inferior to the fixed quantity of 20 tablets. RESULTS: From September 2020 to March 2022, 18,990 individuals were screened and 5,521 were enrolled (n=2,748 IOPP group, n=2,773 fixed-quantity group). For the primary outcome, IOPP with shared decision making was not inferior to fixed quantity (59.5% vs 60.1%, risk difference 0.67%; 95% CI, −2.03% to 3.37%, noninferiority margin −5.0) and resulted in significantly fewer tablets received (median 14 [interquartile range 4–20] vs 20, P<.001) through 90 days postpartum. CONCLUSION: Compared with fixed quantity, IOPP with shared decision making was noninferior for outpatient postcesarean analgesia at 1 week postdischarge and resulted in fewer prescribed opioid tablets at discharge. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT04296396.

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Section: Discussionmentioning

confidence: 68%

Optimizing Opioid Prescription Quantity After Cesarean Delivery

Smid,

Clifton,

Rood

et al. 2024

Obstetrics &Amp; Gynecology

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“…Previously studied risk factors for greater perioperative pain and opioid use in the obstetric population are mostly limited to individual demographics and clinical characteristics, 4,5,9,24,25,26,27,28,29,30,31 while the literature in non-obstetric populations suggests that predictors include objective pain responsiveness assessed via quantitative sensory testing, psychosocial characteristics (e.g., depression, pain catastrophizing), and genetic factors. 16 Though the current results indicate that BE is unlikely to be of value as a biomarker in personalized pain medicine algorithms, alternative biomarkers such as endocannabinoids which have potential interactive effects with endogenous opioids 32,33 should be further explored.…”

Section: Discussionmentioning

confidence: 99%

Prospective evaluation of cerebrospinal fluid levels of β-Endorphin as a predictor of opioid use after scheduled cesarean delivery

Pham

Osmundson

Pedowitz

et al. 2023

Preprint

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Background Prior laboratory work indicates that lower endogenous opioid function is associated with greater analgesic and subjective responses to opioid analgesics. We evaluated whether lower preoperative cerebrospinal fluid (CSF) levels of the analgesic endogenous opioid β-Endorphin (BE) were associated with increased opioid use after cesarean delivery (CD). Methods We enrolled 136 pregnant women without opioid use or chronic pain who were undergoing CD under regional anesthesia. Preoperatively, participants completed validated pain measures and biospecimens were collected to assess BE levels in plasma and CSF. Postoperatively, pain measures at 48 hours and 2 weeks postpartum were assessed. We evaluated the association between CSF BE levels and total opioid use (in morphine milligram equivalents; MMEs) using linear regression controlling for confounding factors (primary analysis). In secondary analyses, we examined: 1) associations between plasma BE levels and total opioid use, and 2) associations between CSF and plasma BE levels and secondary outcomes (inpatient versus outpatient opioid use, pain intensity). Results Participants completed surveys with 100% response rate. The majority were non-Hispanic white (65%), college educated (58%), had private insurance (71%), and had a prior cesarean delivery (69%). Psychiatric diagnoses (depression or anxiety) were common, both currently (22%) and in the past (26%).The median total opioid use across the inpatient and 2-week postpartum follow-up period was 89.1 milligram morphine equivalents (IQR 25–138). Preoperative cerebrospinal fluid β-Endorphin levels were not associated with total opioid use (beta = -0.05, SE 0.45, p = 0.64). Similar findings were noted for plasma β-Endorphin levels. cerebrospinal fluid β-Endorphin levels were only weakly correlated with plasma β-Endorphin levels (r = 0.30, p < .01). Preoperative cerebrospinal fluid and plasma β-Endorphin levels were both positively associated with postpartum pain measures (cerebrospinal fluid: at 48 hours, beta = 0.19, SE 0.16, p < 0.05; Plasma: at 48-hours, beta = 0.02, SE 0.03, p = 0.02, and at 2-weeks, beta = 0.27, SE 0.03, p < 0.01). Conclusions Lower preoperative cerebrospinal fluid levels of β-Endorphin are not associated with increased opioid analgesic use after scheduled cesarean delivery. It is possible that unassessed variability in baseline opioid receptor sensitivity may have confounded ability to test associations between β-Endorphin levels and opioid use outcomes.

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“…[1][2][3][4] Although opioid analgesics can be an important tool to help manage pain, both during the inpatient stay and postdischarge, many patients achieve adequate pain control after cesarean delivery without the use of opioids. 5 Furthermore, the link between higher amounts of inpatient opioid use and greater postdischarge use has raised concerns, 6 prompting a laudable goal of reducing opioidrelated side effects in patients and minimizing opioids in breast milk. 7 Given known opioid-related risks, it is important to understand factors that explain variability in and are associated with greater postoperative pain and opioid consumption, which could help identify patients that might benefit from more judicious use of opioids and augmented nonopioid adjuvant therapies.…”

Section: Methodsmentioning

confidence: 99%

Brief Assessment of Patient Phenotype to Explain Variability in Postsurgical Pain and Opioid Consumption after Cesarean Delivery: Performance of a Novel Brief Questionnaire Compared to Long Questionnaires

He,

Wilson,

Fields

et al. 2024

Anesthesiology

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Background Understanding factors that explain why some women experience greater postoperative pain and consume more opioids after cesarean delivery (CD) is crucial to building an evidence base for personalized prevention. Comprehensive psychosocial assessment with validated questionnaires in the preoperative period can be time-consuming. A 3-item questionnaire has shown promise as a simpler tool to be integrated into clinical practice, but its brevity may limit the ability to explain heterogeneity in psychosocial pain modulators among individuals. We compared the explanatory ability of 3 models: (1) the 3-item questionnaire, (2) a 58-item questionnaire (Long) including validated questionnaires (e.g., BPI, PROMIS) plus the 3-item questionnaire, and (3) a novel 19-item questionnaire (Brief) assessing several psychosocial factors plus the 3-item questionnaire. Additionally, we explored the utility of adding a pragmatic quantitative sensory test (QST) to models. Methods In this prospective, observational study, 545 women undergoing CD completed questionnaires pre-surgery. Pain during local anesthetic skin wheal prior to spinal placement served as a pragmatic QST. Postoperatively, pain and opioid consumption were assessed. Linear regression analysis assessed model fit and the association of model items with pain and opioid consumption during the 48 hours following surgery. Results A modest amount of variability was explained by each of the 3 models for postoperative pain and opioid consumption. Both Brief and Long questionnaire models performed better than the 3-item questionnaire, but were themselves statistically indistinguishable. Items that were independently associated with pain and opioid consumption included anticipated postsurgical pain medication requirement, surgical anxiety, poor sleep, pre-existing pain, and catastrophic thinking about pain. QST was itself independently associated with pain across models, but only modestly improved models for postoperative pain. Conclusions The Brief questionnaire may be more clinically feasible than longer validated questionnaires, while still performing better and integrating a more comprehensive psychosocial assessment than the 3-item questionnaire.

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Predictors of patient post-discharge opioid use after cesarean delivery: a prospective study

Cited by 3 publications

References 7 publications

Optimizing Opioid Prescription Quantity After Cesarean Delivery

Optimizing Opioid Prescription Quantity After Cesarean Delivery

Prospective evaluation of cerebrospinal fluid levels of β-Endorphin as a predictor of opioid use after scheduled cesarean delivery

Brief Assessment of Patient Phenotype to Explain Variability in Postsurgical Pain and Opioid Consumption after Cesarean Delivery: Performance of a Novel Brief Questionnaire Compared to Long Questionnaires

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