CLINICAL QUESTION

Can routine opioid prescribing after cesarean delivery be successfully replaced with an individualized approach that reduces outpatient opioid prescriptions?

BOTTOM LINE

A personalized protocol for opioid prescribing at discharge after cesarean delivery reduced opioid prescriptions by an average of approximately 100 morphine milliequivalents per patient compared with traditional routine opioid prescribing. A large proportion (43%) did not receive any opioid prescription at discharge. Emergency department visits for uncontrolled pain increased by approximately 1%. Only 2.2% used the hotline to report uncontrolled pain. The change in outpatient opioid prescribing was related to a change in inpatient and outpatient pain management that routinely relies on scheduled ibuprofen and acetaminophen, with opioids only as needed. (Level of Evidence = 2b)

SYNOPSIS

This was a prospective cohort study of pain management in all patients who underwent cesarean delivery over a 6-week period at one institution. The institution adopted a personalized protocol, and at discharge, each patient was prescribed scheduled ibuprofen, 800 mg (30 tablets), and acetaminophen, 325 mg (100 tablets), with a prescription for oxycodone tablets equal to five times the morphine milliequivalents used in the 24 hours before discharge. The comparison group was a retrospective group from the same institution for a 6-week period in the same season but not the same dates (n = 367). The previous protocol was to prescribe 30 tablets of acetaminophen/codeine at discharge for all patients. The median morphine milliequivalents prescribed for the personalized group at discharge were lower than those of the comparison group (37.5 vs. 135). With personalized prescribing, the median number of oxycodone tablets prescribed was five, and 43% of patients received no opioid prescription at discharge. For the individualized cohort, the authors implemented a hotline to call in case of uncontrolled pain, which was used by nine patients (2.2%). None of the hotline callers had followed the scheduled ibuprofen and acetaminophen regimen, none of the callers required an opioid prescription, and none presented to the emergency department after calling. The personalized cohort had 11 emergency department visits because of pain (2.7%) vs. six in the traditional prescribing cohort (1.6%); no patients in either cohort required readmission or an opioid prescription. The authors calculated that this practice change in one institution reduced the prescription of opioid tablets in their community by approximately 90,000 per year.