Opioid-free multimodal analgesia pathway to decrease opioid utilization after cesarean delivery.

AIM: To evaluate an opioid-free multimodal analgesic pathway (MAP) to decrease opioid utilization after cesarean delivery (CD) compared to historic data of our institution prior to using MAP for pain management (pre-MAP). METHODS: The MAP was implemented in three phases from September 2018 to August 2019. Patients received 1000 mg intravenous (IV) acetaminophen with 30 mg IV ketorolac at 0 (arrival time at recovery room), 6, 12 and 18 h of postoperative course. On the 2nd and the 3rd postoperative days, patients were monitored for pain every 6 h by Numeric Pain Intensity Scale (0 = no pain to 10 = severe pain) and administered 600 mg oral ibuprofen for a pain score between 0 and 4, 600 mg oral ibuprofen and/or 650 mg oral acetaminophen for a pain score between 5-6, 1000 mg IV acetaminophen and/or 30 mg of IV or intramuscular ketorolac for a pain score between 7 and 10. Five milligrams of oral oxycodone was reserved for rescue if all protocol options were exhausted. Patients were discharged with 600 mg oral ibuprofen without opioid prescription. Likert surveys measuring patient satisfaction of pain control were administered during phase 3. RESULTS: Inpatient and outpatient opioid consumption rates were significantly decreased from 45%, 18% to 23.8%, 8.5% after MAP implementation (P-value <0.001). More than 90% of patients reported that their pain was well controlled and willing to request the same regimen for a future CD. CONCLUSION: MAP Implementation after CD significantly reduced inpatient and outpatient opioid consumption compared to pre-MAP results while maintaining high patients' satisfaction with pain control.

Post-cesarean delivery outpatient opioid consumption and perception of pain control following implementation of a restrictive opioid prescription protocol.

BACKGROUND: Cesarean delivery is the most common laparotomy performed in the United States and can be the first exposure to opioids for many women. Unnecessary consumption of opioids may lead to long-term addiction and further perpetuate this national health crisis. OBJECTIVES: The primary objective of the study was to assess whether a quality improvement initiative by means of a restrictive opioid prescription policy decreases opioid consumption and maintains patient satisfaction after cesarean delivery. A secondary objective is to correlate opioid consumption with demographic and perioperative factors. MATERIALS AND METHODS: A Plan, Do, Check, Act model was used to implement a quality improvement initiative. A restrictive opioid prescribing policy was put in place in July 2017 preventing all physicians from prescribing opioids to their patients upon discharge after cesarean delivery; patients could call their providers from home to request additional analgesia (opioid or nonopioid) if pain was not sufficiently controlled. From August 2017 to February 2018, a postdischarge telephone interview assessing pain control satisfaction and opioid consumption was conducted for all English-speaking patients in our hospital who underwent a cesarean delivery. Statistical analysis was performed using IBM SPSS 22.0, with P < .05 reported as statistically significant. RESULTS: A total of 283 parturients were interviewed 8-33 days after cesarean delivery (mean, 16 days). After implementation of the restrictive opioid prescription policy, we observed a decrease in opioid prescriptions at discharge after cesarean delivery from 97.9% to 0%, with an 18% prescription rate after discharge. Patients reported high satisfaction with their pain control, with 89% (n = 253) stating that their pain was adequately controlled upon discharge. Although 90% (n = 256) reported that they did not need any pain medication other than ibuprofen or acetaminophen, opioids were prescribed to 18% of patients (n = 51) after discharge, with only 51% of these women (n = 27) consuming them. In response to the restrictive opioid prescribing policy, only 13% of the women (n = 37) reported that they wished that a stronger pain medication had been prescribed after hospital discharge. Factors associated with opioid consumption postdischarge included white race/ethnicity, multiparity, and opioid consumption during inpatient hospitalization. CONCLUSION: Following implementation of the restrictive opioid prescribing policy, most women experienced adequate pain control after cesarean delivery. Patient satisfaction with pain control was high, showing that it is feasible to implement restrictive opioid prescription policies while maintaining a high satisfaction rate.