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Opioids Over-Prescribed Following Cesarean Delivery

June 19, 2017
Many women are prescribed more opioids than needed after C-section, creating a risk for misuse and diversion.

Interviews with Brian Bateman, MD, Whitney You, MD, and Nicole Higgins, MD

Physicians routinely over-prescribe opioids to patients who undergo Cesarean sections, according to a group of studies published online on June 8, 2017 in the journal Obstetrics & Gynecology. The studies suggest physicians should consider more carefully the number of pills they prescribe in order to reduce the number of leftover tablets and the potential for misuse of these drugs.

One study showed that including patients in the decision-making process about the quantity of opioids they receive post-procedure helped reduce the number of pills prescribed while still providing sufficient pain relief and patient satisfaction.

Over 1 million C-sections are performed each year. Although women are unlikely to get hooked on opioids after a C-section, NSAID should be the preferred nonopioid treatment of choice for the majority of women, with opioids reserved for breakthrough or severe pain.

Research Overview

Two of the studies focused on the amount of opioids prescribed. The first study found that patients routinely received about twice as many pills as they used and had an average of 15 pills left over.1 The researchers also found that if patients are prescribed more, they use more. “When patients are prescribed a large amount [of pills] they assume they are supposed to take more and when they are prescribed a small amount, they assume they are supposed to take less,” said Brian Bateman, MD, the study’s lead author and chief of Obstetrics Anesthesia at Brigham & Women’s Hospital.

The study also found that lower-quantity prescriptions did not lead to an increase in pain scores. “We found that…there was no association between the amount prescribed and the patient’s reported pain scores or their satisfaction,” said Dr. Bateman. “However, with larger amounts, there was a higher rate of opioid-related side effects.”

The second study found wide variations in prescribed doses, with a range of 8 to 84 pills, or the equivalent of 2 days to 3 weeks of treatment when taken 4 times a day.2 Seventy-five percent of the study participants had pills left over and a large majority of those (63%) kept them in an unsecured location.

A third study, also conducted by Dr. Bateman and colleagues,3 required patients to attend a 10-minute meeting in which a clinician discussed the amount of pain to expect after a Cesarean delivery, the risks and benefits of both opioids and non-narcotic analgesics, how to get refills, and how to safely dispose of unused pills. During the meeting, participants also watched an informational presentation on a tablet computer. Following the meeting, patients were asked how many pills (oxycodone 5 mg) they would like to receive following their procedures. The median number of tablets chosen was 20—half the institutional standard of 40 pills. Of these patients, 9 out of 10 reported satisfaction with their pain relief.

“This is a promising approach to better align what patients actually need with what they’re prescribed,” said Dr. Bateman. And because patients receive instructions for proper pill disposal, this method also helps to reduce the number of leftover drugs that could be diverted and misused.

Resolution of Post-Procedure Pain

More than 1 million Cesarean sections are performed annually in this country, according to the Centers for Disease Control and Prevention (CDC). The procedure involves a large abdominal incision and trauma to surrounding tissues, causing acute pain that can be severe during the first few days following surgery. Barring complications, the pain resolves completely for most patients over 4 to 6 weeks.

“I tell my patients that the worst day is the day after the procedure” when the regional anesthetic starts to wear off, said Whitney You, MD, assistant professor of Obstetrics and Gynecology at Northwestern University Feinberg School of Medicine. Dr. You describes a 6-week recovery period in which pain subsides fairly quickly in the first 2 weeks while patients gradually take on more activities of daily living, eventually resuming all normal activities by the end of week 6. Though some patients recover more quickly, Dr. You said, it’s important to encourage realistic expectations. “By the end of 6 weeks, I expect them to feel almost completely normal again.”

Patients experience pain and respond to analgesics differently. Some can manage without opioids, relying exclusively on NSAIDs; many others use opioids sparingly, for breakthrough pain only; and some require opioids more often and for longer periods of time. These wide variations make it difficult to set a hard and fast rule for the amount of opioids to prescribe following Cesarean delivery.

Dr. You said she typically sends mothers home with 2 prescriptions, 1 for an NSAID and another for an opioid. Patients are instructed to take the NSAID on schedule, around the clock, even if they are feeling fine, and to rely on the opioid for any breakthrough pain. Because doctors can’t determine ahead of time which patients will experience more pain, they often prescribe more pills to ensure those who need them will have enough.

Dr. You notes that return visits to get a refill can be difficult for a patient who is not only recovering from surgery but also caring for an infant. “We can’t prescribe [opioids] over the phone, so they have to come in for the prescription and that can certainly be problematic,” she said. “I would say that is my driving factor for the amount I prescribe,” usually 30—45 pills.

According to Nicole Higgins, MD, associate professor and medical director of Obstetric Anesthesia at Northwestern Memorial Hospital (NMH), doctors’ understandable desire to keep their patients comfortable may contribute to variations in prescribing practices. “I think this is physicians wanting to provide enough pain medication for their patients,” she said. She suggests the amount they prescribe may also be what they learned to give while they were in training.

Over-prescribing may also be patient-driven. Many mothers anticipating Cesarean delivery are anxious about the pain they expect to experience post-procedure, said Dr. Higgins. “There’s a fear that [they are] going to be in so much pain,” and as soon as they feel a twinge, they want to take something to make it go away.

Patient Aversion to Opioids

While some patients are especially pain averse, Dr. You said she also sees patients who are reluctant to take opioids. They have heard about the dangers these drugs can pose and are concerned for their health and that of their babies. In these cases, Dr. You sends mothers home with NSAIDs or acetaminophen only, instructing them to take the analgesics around the clock and on schedule. “I just had a patient who didn’t want to take opioids, and she’s doing very well on the Tylenol/Motrin regimen.”

When opioids are prescribed, Dr. You provides patients with a stool softener to prevent constipation—one of the most common side effects of the drugs. Other side effects, such as nausea and fatigue, can present problems for patients and may mean stopping the drug or reducing the dosage. All patients are instructed not to drive while taking opioids.

Opioids and Nursing

Breastfeeding has become increasingly common for American mothers over the last 30 years, and they often ask if it is safe to take opioids while nursing.

While breastfeeding is generally considered safe in the amounts and for the length of time most obstetricians prescribe, a recent practice advisory urges doctors to exercise caution when prescribing codeine and tramadol to breastfeeding mothers because the drugs have been associated with “the potential for serious adverse effects in the infant due to opioid overdose” and central nervous system depression, which scientists attribute to individuals’ varying rates of opiate metabolism.

The advisory was issued by The American College of Obstetricians and Gynecologists (ACOG), along with the Society for Maternal-Fetal Medicine and the Academy of Breastfeeding Medicine. This followed a Drug Safety Communication issued by the US Food and Drug Administration regarding potential dangers of codeine and tramadol for nursing infants

Dr. You does not prescribe codeine or tramadol to her nursing mothers. For those doctors who do, she recommends that they counsel their patients about the potential harm to the infant associated with these drugs. “We don’t know about all opioids and the risks of neonatal depression,” she said, “so we are being more careful and having more discussions with patients and families about these risks.”

A Multimodal Approach

According to the ACOG advisory, “Safe management of pain…begins with maximizing the use of multimodal nonopioid analgesics such as regional anesthetic techniques, nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen.” Dr. Higgins said that this is the approach she and her colleagues take. Patients are sent home with NSAIDs to take on schedule, around the clock, along with an opioid that they are usually advised to take as needed, for breakthrough pain only. Regional nerve blocks can also be used to help reduce any pain along the incision, and simple non-medical devices, such as an abdominal binder, can be provided to help reduce any soreness associated with healing abdominal muscles post-procedure.

Involving Patients in Pain Management

One of the studies’ most promising findings is that shared decision-making with patients can have a dramatic effect on reducing the amount of leftover medication while still providing satisfactory pain control following Cesarean delivery. Dr. Bateman and his colleagues are now exploring whether this approach can also work for other specialties that rely on opioids. Physicians are eager to find new methods and welcome innovations that will help them successfully manage their patients’ pain while reducing leftover pills and avoiding harm to others.

Last updated on: June 19, 2017
Continue Reading:
Prescribing Opioids: How New Policies Are Affecting Medical Specialties

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