In the JournalsPerspective

Program reduces opioid exposure, improves outcomes after cesarean delivery

Monique Hedderson

Enhanced recovery after surgery, or ERAS, programs may successfully reduce opioid exposure and improve outcomes in women who undergo elective cesarean delivery, according to study results in Obstetrics & Gynecology.

“There are several clinical components to the ERAS program we implemented,” Monique Hedderson, PhD, of the division of research at Kaiser Permanente, told Healio Primary Care. “In addition to the changes in the pain management strategies, the program also aims to decrease the time to first mobilization and the time to first nutrition after surgery. Similar programs can be implemented in other clinical practice settings.”

Researchers collected patient data 12 months before and 12 months after an ERAS program developed for cesarean delivery was implemented at 15 different medical centers. The program was developed by a multidisciplinary team that included obstetricians, anesthesiologists, nursing leaders, perinatologists and neonatologists.

The ERAS program focused specifically on multimodal pain management and reducing opioid exposure, earlier mobility, optimizing maternal nutrition, and engaging with patients.

A total of 4,689 patients were included in the pre-ERAS program group and 4,624 patients were included in the post-ERAS implementation group.

After the ERAS program went into effect, the mean inpatient opioid exposure decreased almost 50%, from 10.7 daily morphine equivalents (95% CI, 10.2-11.3) to 5.4 equivalents (95% CI, 4.8-5.9). The prevalence of dispensed outpatient opioids decreased from 85.9% to 82.2% and the average number of dispensed pills dropped from 38 to 26 (P < 0.001).

Use of multimodal analgesia, such as acetaminophen and neuraxial anesthesia, jumped from 9.7% to 88.8% with the ERAS program.

The amount of time patients reported acceptable pain scores on a visual analog scale increased from 82.1% to 86.4%.

The length of time to ambulation after cesarean delivery was shorted by 2.7 hours (95% CI, –3.1 to –2.4) and the time to first solid food intake decreased by 11.1 hours (95% CI, –11.5 to –10.7) among women who underwent cesarean deliveries after the ERAS program went into effect.

Researchers noted that there were no significant changes in surgical site infections, readmissions, length of hospitalization or breastfeeding rates among the groups before or after the ERAS program was implemented.

“Patients introduced to an opioid during surgery can face an increased risk of developing an opioid use disorder,” Hedderson said. “Thus by reducing opioid use after their cesarean delivery, we may have reduced the risk of developing an opioid use disorder during the postpartum period, which would be detrimental for both the mother and her baby.”

“We found that even though the ERAS protocol was associated with reduced opioid exposure it did not impact the proportion of time patients reported their pain was successfully managed.”

Please visit the Healio Opioid Resource Center — a collection of news articles and features that the latest information on the opioid crisis including treatment strategies, FDA decisions regarding treatments and other important, related announcements.– by Erin Michael

Disclosures: Hedderson reports no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.

 

 

Monique Hedderson

Enhanced recovery after surgery, or ERAS, programs may successfully reduce opioid exposure and improve outcomes in women who undergo elective cesarean delivery, according to study results in Obstetrics & Gynecology.

“There are several clinical components to the ERAS program we implemented,” Monique Hedderson, PhD, of the division of research at Kaiser Permanente, told Healio Primary Care. “In addition to the changes in the pain management strategies, the program also aims to decrease the time to first mobilization and the time to first nutrition after surgery. Similar programs can be implemented in other clinical practice settings.”

Researchers collected patient data 12 months before and 12 months after an ERAS program developed for cesarean delivery was implemented at 15 different medical centers. The program was developed by a multidisciplinary team that included obstetricians, anesthesiologists, nursing leaders, perinatologists and neonatologists.

The ERAS program focused specifically on multimodal pain management and reducing opioid exposure, earlier mobility, optimizing maternal nutrition, and engaging with patients.

A total of 4,689 patients were included in the pre-ERAS program group and 4,624 patients were included in the post-ERAS implementation group.

After the ERAS program went into effect, the mean inpatient opioid exposure decreased almost 50%, from 10.7 daily morphine equivalents (95% CI, 10.2-11.3) to 5.4 equivalents (95% CI, 4.8-5.9). The prevalence of dispensed outpatient opioids decreased from 85.9% to 82.2% and the average number of dispensed pills dropped from 38 to 26 (P < 0.001).

Use of multimodal analgesia, such as acetaminophen and neuraxial anesthesia, jumped from 9.7% to 88.8% with the ERAS program.

The amount of time patients reported acceptable pain scores on a visual analog scale increased from 82.1% to 86.4%.

The length of time to ambulation after cesarean delivery was shorted by 2.7 hours (95% CI, –3.1 to –2.4) and the time to first solid food intake decreased by 11.1 hours (95% CI, –11.5 to –10.7) among women who underwent cesarean deliveries after the ERAS program went into effect.

Researchers noted that there were no significant changes in surgical site infections, readmissions, length of hospitalization or breastfeeding rates among the groups before or after the ERAS program was implemented.

“Patients introduced to an opioid during surgery can face an increased risk of developing an opioid use disorder,” Hedderson said. “Thus by reducing opioid use after their cesarean delivery, we may have reduced the risk of developing an opioid use disorder during the postpartum period, which would be detrimental for both the mother and her baby.”

“We found that even though the ERAS protocol was associated with reduced opioid exposure it did not impact the proportion of time patients reported their pain was successfully managed.”

Please visit the Healio Opioid Resource Center — a collection of news articles and features that the latest information on the opioid crisis including treatment strategies, FDA decisions regarding treatments and other important, related announcements.– by Erin Michael

Disclosures: Hedderson reports no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.

 

 

    Perspective
    Alex F. Peahl

    Alex F. Peahl

    The authors of this article highlight the potential benefits of Enhanced Recovery After Surgery Protocols for women following cesarean delivery, including lower inpatient opioid use, faster time to recovery, and reduced number of patients leaving the hospital with an opioid prescription. These findings echo work done in obstetrics, gynecology and other surgical specialties that demonstrate how standardized pathways using multimodal pain medications can improve recovery and patient experience while reducing opioid use. These efforts are particularly important because we know women who are discharged with a larger opioid prescription are more likely to continue using opioids in the year after delivery. While these findings are reassuring, patients were discharged with an average of 26 tablets of opioid (oxycodone) at the time of discharge, which is higher than recommendations made by opioid stewardship organizations. Considering methods to further reduce outpatient prescribing will be important for balancing the risks of opioids with the benefits of effective pain management.

    • Alex F. Peahl, MD
    • Department of Obstetrics and Gynecology
      University of Michigan

    Disclosures: Peahl reports no relevant financial disclosures.

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