Decreasing Opioid Use Postpartum

Rogers, Rebecca G.; Nix, Michael; Chipman, Zachary; Breen, Michael T.; Dieterichs, Chad; Nutt, Stephanie; Moxham, Jamie; Chang, Patrick; Rathouz, Paul J.; Robertson, Henry; Young, Amy

doi:10.1097/aog.0000000000003512

Cited by 18 publications

(14 citation statements)

References 13 publications

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“…A recent quality improvement study, for example, reviewed approximately 570 charts showing that the group who utilized the multimodal approach was associated with a 75% reduction in in-hospital total morphine milligram equivalents without an increase in measured pain or length of hospital stay [6]. Similarly, Rogers et al recently evaluated the impact of multimodal order set on opioid consumption and pain control in a rather large cohort of patients after vaginal and cesarean deliveries [14]. They reported that opioid use decreased by 26% and 18% among women who delivered vaginally or by cesarean, respectively.…”

Section: Discussionmentioning

confidence: 99%

Implementation of a Standardized Post-Cesarean Delivery Order Set with Multimodal Combination Analgesia Reduces Inpatient Opioid Usage

Bornstein

Husk

Lenchner

et al. 2020

JCM

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Background: Opioid use has emerged as a leading cause of death in the US. Given that 1 in 300 opioid-naive patients exposed to opioids after cesarean birth will become persistent users, hospitals should strive to limit exposure to these medications. We set out to evaluate whether transitioning to a standardized order set based on multimodal combination analgesic therapy decreases the exposure to opioids after cesarean delivery. Methods: Our health system’s post-cesarean pain management electronic medical record (EMR) order set was changed from standing NSAIDs (Ibuprofen 600 mg every 6 h) and additional acetaminophen and opioid medications (Oxycodone 5 mg/acetaminophen 325 mg every 3 h or Oxycodone 10 mg/acetaminophen 650 mg every 6 h for moderate and severe pain, respectively) as needed (PRN) to a multimodal combination therapy with acetaminophen (975 mg every 6 h) and NSAIDs (Ibuprofen 600 mg every 6 h) as primary analgesics and opioids PRN (Oxycodone immediate release (IR) 5 mg every 3 h for moderate to severe pain). We performed a retrospective analysis across seven hospitals comparing inpatient opioid use, administration of other analgesics, and severe pain episodes (pain score ≥ 7) between the patients who were treated before and after implementation of the multimodal order set. Chi square and Student t-test were used for statistical analysis with significance determined as p < 0.05. Results: A total of 12,898 cesarean births were included (8696 prior and 4202 after implementation). The multimodal order set was associated with marked decrease in the incidence of post cesarean opioid use (45.4% vs. 67.5%; p < 0.0001), lower average opioid dose (26.7 mg vs. 36.6 mg of oxycodone; p < 0.0001), and increased dose of acetaminophen (8422 mg vs. 4563 mg; p < 0.0001), while severe pain scores were less frequent (46.3% vs. 56.6%, p < 0.0001). Conclusions: Multimodal analgesic therapy for post-cesarean pain management reduces inpatient opioid use while improving pain control. Incorporation of a multimodal order set as a default in the EMR facilitates effective and widespread implementation on a large scale. Obstetric units should consider standardizing post-cesarean pain management orders to include routine (not PRN) multimodal combination therapy with acetaminophen and NSAIDs as primary analgesics.

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Section: Discussionmentioning

confidence: 99%

Implementation of a Standardized Post-Cesarean Delivery Order Set with Multimodal Combination Analgesia Reduces Inpatient Opioid Usage

Bornstein

Husk

Lenchner

et al. 2020

JCM

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“…Opioids were given as needed based on therapeutic postpartum activity goals. The intervention group demonstrated a decrease in opioid use (92% vs 79%; P < .01) and in the amount of morphine milligram equivalents (MME) used (107 MME vs 71 MME; P < .01) 20 …”

Section: Resultsmentioning

confidence: 99%

“…The intervention group demonstrated a decrease in opioid use (92% vs 79%; P < .01) and in the amount of morphine milligram equivalents (MME) used (107 MME vs 71 MME; P < .01). 20 The 4 studies evaluating an intervention that altered medication dosages or timing were all retrospective cohort This study also compared 2 hospitals that conducted the intervention with 2 hospitals that did not conduct the intervention. However, for the purpose of this systematic review, we are only examining changes that occurred at the intervention hospitals.…”

Section: Interventions To Reduce Postpartum Opioid Use During the Inp...mentioning

confidence: 99%

Interventions to Reduce Inpatient and Discharge Opioid Prescribing for Postpartum Patients: A Systematic Review

Badreldin

DiTosto

Holder

et al. 2023

J Midwife Womens Health

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Introduction As deaths related to opioids continue to rise, reducing opioid use for postpartum pain management is an important priority. Thus, we conducted a systematic review of postpartum interventions aimed at reducing opioid use following birth. Methods From database inception through September 1, 2021, we conducted a systematic search in Embase, MEDLINE, Cochrane Library, and Scopus including the following Medical Subject Heading (MeSH) terms: postpartum, pain management, opioid prescribing. Studies published in English, restricted to the United States, and evaluating interventions initiated following birth with outcomes including an assessment of change in opioid prescribing or use during the postpartum period (<8 weeks postpartum) were included. Authors independently screened abstracts and full articles for inclusion, extracted data, and assessed study quality using the Grading of Recommendations, Assessment, Development, and Evaluation tool and risk of bias using the Institutes of Health Quality Assessment Tools. Results A total of 24 studies met inclusion criteria. Sixteen studies evaluated interventions aimed at reducing postpartum opioid use during the inpatient hospitalization, and 10 studies evaluated interventions aimed at reducing opioid prescribing at postpartum discharge. Inpatient interventions included changes to standard order sets and protocols for the management of pain after cesarean birth. Such interventions resulted in significant decreases in inpatient postpartum opioid use in all but one study. Additional inpatient interventions, including use of lidocaine patches, postoperative abdominal binder, valdecoxib, and acupuncture were not found to be effective in reducing postpartum opioid use during inpatient hospitalization. Interventions targeting the postpartum period included individualized prescribing and state legislative changes limiting the duration of opioid prescribing for acute pain both resulted in decreased opioid prescribing or opioid use. Discussion A variety of interventions aimed at reducing opioid use following birth have shown efficacy. Although it is not known if any single intervention is most effective, these data suggest that implementation of any number of interventions may be advantageous in reducing postpartum opioid use.

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“…Although maximizing nonopioid medications may be a helpful strategy for patients with complex pain needs like those with OUD and chronic pain, being opioid naive is typically an inclusion criterion for studies. 6,7 Limitations of our study include a relatively small sample size and that it was conducted at a single site that has an opioid-sparing protocol in place. Still, this work generates important insights to guide future work to balance opioid stewardship and harm reduction with adequate pain control in these high-risk populations.…”

Section: Fundingmentioning

confidence: 99%

Postpartum Opioid Prescribing in Patients with Opioid Use Prior to Birth

et al. 2023

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Objective This study aimed to describe opioid prescribing patterns for pregnant patients with a history of or active opioid use to inform postpartum pain management strategies. Study Design We conducted a retrospective cohort analysis of all patients with a history of opioid use disorder (OUD) or chronic pain seen at a single outpatient clinic specializing in opioid use and OUD in pregnancy from January 2019 to August 2021. Patient characteristics, delivery outcomes, and opioid prescribing information were collected through electronic health record fields. We used descriptive statistics to characterize differences in receipt of an opioid prescription, prescription size, and receipt of a prescription refill across three patient groups: patients with OUD on medication, patients with OUD maintaining abstinence, and patients with chronic pain using opioids. In the study period, the institutional average rate of opioid prescribing after cesarean and vaginal birth were 80.0 and 2.8%, respectively. Results Of the 69 patients included in this study, 46 (66.7%) had a history of OUD on medication, 14 (20.3%) had a history of OUD maintaining abstinence, and 9 (13.0%) had a history of chronic pain. Receipt of an opioid prescription after childbirth was more common after cesarean birth (12/23, 52.2%) than vaginal birth (3/46, 6.5%). Refills were common in patients who received an opioid proscription (cesarean: 5/12, 41.7%; vaginal: 1/3, 33.3%). Conclusion Compared with institutional averages, postpartum opioid prescribing rates for people with a history of OUD or chronic pain were 50 to 60% lower for cesarean birth and three times higher for vaginal birth. Future work is needed to balance opioid stewardship and harm reduction with adequate pain control in these high-risk populations. Key Points

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Decreasing Opioid Use Postpartum

Abstract: Personal or nonessential information may be redacted at the editor's discretion.

Cited by 18 publications

References 13 publications

Implementation of a Standardized Post-Cesarean Delivery Order Set with Multimodal Combination Analgesia Reduces Inpatient Opioid Usage

Implementation of a Standardized Post-Cesarean Delivery Order Set with Multimodal Combination Analgesia Reduces Inpatient Opioid Usage

Interventions to Reduce Inpatient and Discharge Opioid Prescribing for Postpartum Patients: A Systematic Review

Postpartum Opioid Prescribing in Patients with Opioid Use Prior to Birth

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