Opioid Use After C-Sections Can Inform Individualized Prescriptions

March 10, 2020 - Knowledge about patients’ opioid use after cesarean section surgery and before discharge could help inform more individualized prescriptions and cut down on unnecessary, leftover pills, a study published the Annals of Family Medicine showed.

Cesarean delivery surgery is the most commonly performed procedure in the US, with 1.23 million performed in 2017. Most patients receive a prescription for opioids upon discharge from the hospital, and while persistent opioid use following cesarean delivery is uncommon, overprescribing poses a potential risk of nonmedical use.

Researchers noted that in the US, 53 percent of people who abuse opioid prescriptions report getting their last pill from a friend or family member. Additionally, up to 77 percent of individuals store their opioid medications in unlocked locations.

"Leftover opioids fuel nonmedical use," said Karsten Bartels, associate professor of anesthesiology at the University of Colorado Anschutz Medical Campus and senior author of the study. "While it's impossible to make a direct link, we can be cautious by avoiding large amounts of unnecessary opioids.”

Although opioid overprescribing presents significant risks, providers recognize that there is a delicate balance between limiting excess opioid medications and providing patients with adequate pain relief.

“Undertreatment of pain in patients undergoing cesarean delivery has been associated with an increased risk of chronic pain, postpartum depression, negative impacts on infant care, and difficulty breastfeeding,” researchers said.

“Currently, limited data exist to guide discharge opioid prescribing for postcesarean patients, resulting in marked variability in prescribing practices.”

Researchers sought to define patient and procedural characteristics that are association with high versus low opioid use post discharge after cesarean delivery. The team examined opioid use by 203 cesarean delivery patients for 24 hours pre-discharge. Patients then self-reported opioid use for four weeks after surgery.

Researchers found that patients who took fewer opioids pre-discharge also reported less opioid intake in the following weeks, but most patients received similar, non-individualized prescriptions. There were 1,805 leftover pills from patients participating in this study alone. Just 16 percent reported storing leftover pills in a locked location, and only four percent reported discarding their leftover medication altogether.

“This situation represents a substantial potential risk to children, family members, and visitors in the home given the potential for accidental ingestion or diversion of unused opioids. It is critical to establish better prescribing guidelines and practices in order to minimize this potential harm in our communities,” researchers said.

The opioid epidemic and its devastating impact on population health has been well-documented in the last few years, with federal agencies, patient safety organizations, and provider institutions developing strategies to combat addiction.

A 2018 survey conducted by the University of Phoenix showed that nearly 50 percent of registered nurses expect opioid abuse to have a detrimental effect on population health over the next five years. Fifty-one percent of administrative staff said the same.

“Having all groups indicate that opioid abuse is a top concern reinforces how, while this topic continues to dominate headlines, more work is needed to reduce this number and find alternative treatment methods,” Holly Orozco, Dr. PH, dean for the College of Humanities and Sciences at University of Phoenix, said at the time.

“To make meaningful progress on this issue, we need to know what treatment methods people are currently using, understand the training healthcare professionals have to pinpoint potential addictions, and do more research on how to improve both training and access to appropriate treatments for those who suffer from pain.”

Researchers from CU Anschutz stated that while there are evidence-based guidelines to reduce the degree of overprescribing in the postoperative setting, there are no such guidelines for patients undergoing cesarean delivery. The team believes their method is an effective way to tailor opioid medications for each patient.

“Prescribing post-op discharge opioids based on last 24-hour use is a simple, practical tool to inform appropriate prescriptions - indeed, this practice is now being adopted for our patients at CU Anschutz,” said Bartels. “If we would re-do the study today, we would likely see many more individualized and lower prescriptions."

While the study does emphasize the need to prevent overprescribing, the team also pointed out that providers should address regular pain management.

"Identify those who do need prescriptions," Bartels said. "Opioids can be detrimental to public health but can also be a godsend."

Regulating and personalizing opioid prescriptions among patients will ultimately require standard provider training and education, researchers said.

“Clinician education will be essential in changing opioid-prescribing practices, which currently vary widely between clinicians and institutions. Future studies will need to evaluate the impact of implementing evidence-based interventions on both clinician prescribing practices and potential undertreatment of pain,” the group concluded.