Postcesarean Opioid Prescribing Cut by Intervention

Nicola M. Parry, DVM

June 15, 2017

Use of a shared decision-making tool to optimize women's pain management after cesarean delivery halves the number of prescribed oxycodone tablets, a new study shows.

Malavika Prabhu, MD, from Harvard Medical School, Boston, Massachusetts, and colleagues published the results of their study online June 6 in Obstetrics & Gynecology.

"This approach is a promising strategy to reduce the amount of leftover opioid medication after treatment of acute postcesarean pain," the authors write.

Cesarean delivery is the most commonly performed inpatient surgery in the United States, and women are frequently prescribed opioids after delivery. However, studies have suggested that women are prescribed significantly more opioids than they need for postcesarean pain control.

Indeed, two additional papers in the same issue of the journal also highlight this problem. One showed that women undergoing cesarean delivery were prescribed twice as many opioid tablets as they needed for pain control. The second showed that more than 75% of women had an average of 10 oxycodone pills left over after cesarean delivery, and that only 6% of these women had disposed of their extra pills.

This problem inevitably leads to large amounts of unused opioids that are available for diversion and misuse.

Because shared decision making has been shown to improve clinical outcomes and patient satisfaction in numerous clinical settings, Dr Prabhu and colleagues conducted a study to examine how this type of intervention would affect the number of oxycodone tablets prescribed to women after cesarean delivery.

In the study, 50 women undergoing cesarean delivery each participated in a shared decision-making session with a clinician. During the session, participants viewed a tablet-based decision aid while the clinician discussed relevant information, including about anticipated pain in the first 2 weeks after cesarean delivery, expected opioid use, and the risks and benefits of opioid and nonopioid pain medications. At the end of their session, each participant chose the number of tablets (oxycodone 5 mg) she would be prescribed at discharge (up to the institutional standard prescription of 40 tablets).

Using this shared decision-making approach significantly reduced the number of opioids prescribed to women at the time of discharge. Participants selected a median of 20.0 (interquartile range [IQR], 15.0 - 25.0) oxycodone tablets compared with the 40 tablets usually prescribed (P < .001).

During the first 2 weeks after discharge, the women used a median of 15.5 (IQR, 8.0 - 25.0) oxycodone tablets, and a median of 4.0 (IQR, 0.0 - 8.0) tablets were left over.

According to the authors, 52.0% of women reported being satisfied and 38.0% very satisfied with their pain management. Most (86.0%) women also found the shared decision-making tool valuable to their postoperative care.

The researchers also found that the refill rate was low. Only four women (8.0%) required oxycodone refills; of these, three had experienced complications, and the fourth had experienced continued postoperative pain. These four women had initially chosen 5, 30, 30, and 40 oxycodone tablets, and were subsequently prescribed 20 to 30 additional tablets.

At follow-up, among the women who did not require a refill and who had unused oxycodone tablets, 11 (34.3%) had plans to flush the unused tablets, 10 (31.3%) had plans to return them to a disposal station, and only 11 (34.3%) had no plans for their disposal.

"[O]ur study demonstrates that shared decision making is a promising strategy to align opioid prescribing with patient needs after cesarean delivery and thus may reduce the number of unused opioid tablets in the community while still ensuring adequate pain control and patient satisfaction," the authors conclude.

In an accompanying editorial, Stephen W. Patrick, MD, MPH, from Vanderbilt University, Nashville, Tennessee, emphasizes the opioid epidemic as "an exponentially expanding public health problem in the United States."

Opioid use is increasing among all populations, he says, including among women of reproductive age and pregnant women. Dr Patrick highlights a report from the Centers for Disease Control and Prevention that showed that almost one third of women of reproductive age were prescribed an opioid in the previous year.

Rates of opioid use disorder among pregnant women are also rising, he notes, as is the number of newborns diagnosed with neonatal abstinence syndrome.

"Treatment needs are particularly pressing for the vulnerable population of pregnant women with opioid use disorder and their newborns," stresses Dr Patrick, adding that treatment must be gender-specific, multidisciplinary, and comprehensive. Ideally it should also extend from the prepregnancy period to the infant and developing child, he writes.

"The stakes are high, and collectively we must have a thoughtful public health response that is grounded in both research and compassion," Dr Patrick concludes.

This study was supported by a grant awarded to a coauthor from the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health. One coauthor reports receiving grants from Lilly, Pfizer, Baxalta, GlaxoSmithKline plc, and Pacira. Another coauthor reports receiving a grant from Pacira. The remaining coauthors of the primary study and the editorialist have disclosed no relevant financial relationships. Two authors of another study report grants to their institutions from Lilly, Pfizer, Baxalta, GSK, and Pacira.

Obstet Gynecol. Published online June 6, 2017. Article abstract, Editorial extract

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