Effect of a stepwise opioid-sparing analgesic protocol on in-hospital oxycodone use and discharge prescription after cesarean delivery

Abstract

IntroductionOpioid exposure during hospitalization for cesarean delivery increases the risk of new persistent opioid use. We studied the effectiveness of stepwise multimodal opioid-sparing analgesia in reducing oxycodone use during cesarean delivery hospitalization and prescriptions at discharge.MethodsThis retrospective cohort study analyzed electronic health records of consecutive cesarean delivery cases in four academic hospitals in a large metropolitan area, before and after implementation of a stepwise multimodal opioid-sparing analgesic computerized order set coupled with provider education. The primary outcome was the proportion of women not using any oxycodone during in-hospital stay (‘non-oxycodone user’). In-hospital secondary outcomes were: (1) total in-hospital oxycodone dose among users, and (2) time to first oxycodone pill. Discharge secondary outcomes were: (1) proportion of oxycodone-free discharge prescription, and (2) number of oxycodone pills prescribed.ResultsThe intervention was associated with a significant increase in the proportion of non-oxycodone users from 15% to 32% (17% difference; 95% CI 10 to 25), a decrease in total in-hospital oxycodone dose among users, and no change in the time to first oxycodone dose. The adjusted OR for being a non-oxycodone user associated with the intervention was 2.67 (95% CI 2.12 to 3.50). With the intervention, the proportion of oxycodone-free discharge prescription increased from 4.4% to 8.5% (4.1% difference; 95% CI 2.5 to 5.6) and the number of prescribed oxycodone pills decreased from 30 to 18 (−12 pills difference; 95% CI −11 to −13).ConclusionsMultimodal stepwise analgesia after cesarean delivery increases the proportion of oxycodone-free women during in-hospital stay and at discharge.

The risk of serious opioid-related events associated with common opioid prescribing regimens in the postpartum period after cesarean delivery

“…27 A recent study from 2 hospitals that implemented an initiative to reduce opioid prescribing after cesarean in 2017 demonstrated the mean and median number of tablets prescribed at discharge after cesarean was 18 oxycodone tablets after the intervention (interquartile range: 16-20). 28 Assuming a 5 mg formulation, 18 oxycodone tablets represents a total of 135 MME, an average dose associated with a substantial risk increase, according to our estimates.…”

“…Importantly, the tablet number may have been even higher in non-intervention hospitals. 28 A recent study from a tertiary academic medical center in Missouri reported a median prescribed total dose of 150 MME at discharge after cesarean in 2018 (equal to 20 oxycodone 5-mg tablets). 29 In a separate study of a tertiary academic medical center, the median prescribed total opioid dose was 110.7 MME in 2018, even after the passage of HB 21 that restricted opioid prescriptions to a 3-day supply (or 7-days with exemption request).…”

Effectiveness of organisational interventions on the appropriate use of opioids for non-cancer pain upon hospital discharge: A systematic review

“…Of the 43 articles included in this review, there were three randomised controlled trials (RCTs), [14][15][16] four cohort studies, [17][18][19][20] one case-control study 21 and 35 pre-post intervention/interrupted time series studies. Nineteen studies involved patients discharged from the ED, 15,16,[22][23][24][26][27][28][29]31,34,[39][40][41][42]46,48,50,56 four focused on women recovering from caesarean delivery, 18,25,32,45 eight looked at all surgical patients, 14,20,33,35,42,[52][53][54] and four involved all discharge patients. 38,42,55,56 The remaining studies focused on more specialised surgical procedures including endocrine, orthopaedic and cardiac surgery.…”

“…The studies included were conducted in the United States of America (n=34), [15][16][17][18][19][20][21][22][23][24][25][26][27][28][30][31][32][33][35][36][37][38][39][40][41][43][44][45][47][48][49][50]55,56 Australia (n=8) 14,29,34,42,[51][52][53][54] and the United Kingdom (n=1). 46 There were 16 studies which employed a multifaceted intervention, 16,18,24,25,31,37,38,42,45,46,49,[50]…”

“…Sixteen studies implemented multiple intervention strategies to improve prescribing on hospital discharge. 16,18,24,25,31,37,38,42,45,46,49,[50][51][52]54,55 The majority of these studies included health professional education in conjunction with other interventions.…”