Opioids often prescribed after cesarean delivery even when not needed

Nearly 90% of women who did not use opioids in the hospital after cesarean delivery were nonetheless discharged with a prescription for opioids, according to a study presented at the Anesthesiology 2019 annual meeting. A related study showed opioid prescribing upon discharge remained high, even after improvements were made to effectively manage pain after cesarean delivery with other medications during patients' hospital stays.

The opioid crisis has been fueled by excessive and unnecessary prescriptions after surgery. Cesarean delivery is the most common inpatient procedure in the U.S. with more than 1 million performed annually.

"Health care providers need to focus on reducing opioid use after cesarean delivery, both in the hospital and at discharge, using effective alternative pain medications. We are making progress but more needs to be done," said Ruth Landau, M.D., senior author of the two studies and director of obstetric anesthesia at Columbia University Medical Center, New York. "Women also need to be their own advocates, insisting on opioids only when absolutely necessary. In addition to the risk of addiction, opioids can cross into breast milk and studies have shown they can increase the risk of sleepiness and breathing problems in newborns."

In 2017, Columbia instituted a new physician anesthesiologist-led pain management protocol in which women received standard scheduled ibuprofen and acetaminophen every six hours after cesarean delivery while in the hospital. Opioids were given only for persistent pain: 5 mg of oxycodone every four hours for moderate pain and every three hours for severe pain. The researchers compared in-hospital opioid use in 491 women before the new protocol (January-April 2017) to 1,125 women after (January-September 2017), they determined:

• Nurses who provided the medication adhered to the new protocol 82.8% of the time
• Cumulative opioid dosage was three times less after the new protocol was in place
• The proportion of women who did not use opioids during their hospital stay increased from 9.6% to 29.8%
• Reduction in opioid consumption was achieved without a negative effect on pain scores or patient satisfaction, according to patient surveys

In 2018, the researchers analyzed opioid prescriptions provided to 1,503 women being discharged from the hospital after cesarean and determined opioid over-prescription occurred in 49.9% of patients. They found:

• 1,449 women (96.4%) received a prescription for opioids at discharge
• 456 women (30.3%) did not use opioids at all after their cesarean delivery, yet 406 (89%) received an opioid prescription at discharge
• 817 women (54.4%) did not use opioids in the last 24 hours of their stay, yet 750 (91.8%) received an opioid prescription at discharge
• Providers prescribed an average of 19.5 opioid pills at discharge

Extrapolating these numbers, researchers estimate it is likely that up to 15,000 leftover pills have accumulated in patients' homes—increasing the risk for opioid abuse, misuse or diversion, just from cesarean deliveries—during a short time period in one academic hospital.

"With a robust intervention targeting the reduction of hospital opioid consumption, we were able to achieve spectacular results, but more steps are needed at the tail end of the patient's hospital stay to further reduce opioid consumption and prescription patterns," said Dr. Landau. "We are working to further educate prescribers to tailor prescriptions at discharge."