Cesarean Delivery as a Pathway to Nonmedical Opioid Use

Summary and Comment |
July 28, 2017

Cesarean Delivery as a Pathway to Nonmedical Opioid Use

  1. Anna Wald, MD, MPH

Are clinicians providing too many pills after cesareans?

  1. Anna Wald, MD, MPH

Opioid-related death rates are rising among child-bearing women, whose drug use often originates with prescribed medication. In particular, pain management after cesarean delivery (the most common major surgery in the U.S.) presents an opportunity for excessive use or abuse. Investigators at one U.S. academic center queried 179 women 2 weeks after cesarean delivery regarding their use of the opioids they had received (most commonly, 30 pills of 5-mg oxycodone). After discharge, 22% took all prescribed opioids, 61% took some, and 17% took none. About 75% had leftover opioids (median, 10 pills). Women who took more opioids while in the hospital (as well as smokers) were more likely to take more pills after discharge.

In a survey of 720 women interviewed 2 weeks after cesarean delivery at 6 U.S. academic centers, a median of 40 pills (mostly oxycodone) were prescribed versus 20 consumed. Fewer than 5% of women with leftover pills had disposed of them. Satisfaction with pain control did not vary with number of pills prescribed, although the number of pills taken correlated with the number prescribed. More women considered the amount of opioids dispensed to be excessive (36%) than insufficient (15%).

In a third study, researchers evaluated a 10-minute shared decision-making intervention about postcesarean opioid use. A physician explained the expected course of postsurgical pain; then, with the assistance of a computer-based decision aid, 51 participants selected the desired number of 5-mg oxycodone pills (standard prescription, 40 pills; offered range, 0–40). A median of 20 pills was selected, and 15 were consumed during the 2 weeks after discharge. Additional prescriptions were necessary for four women, three of whom had complications likely to increase pain.

Comment

These studies show that the quantity of opioids prescribed after cesarean delivery is often excessive. The amount of medication for adequate pain control differs for each woman, so shared decision making seems appropriate. The reasons for this wide spectrum of need for pain control are partly physiologic, but also probably reflect differential social support, understanding of normal postpartum events, and awareness of nonopioid analgesics such as nonsteroidal anti-inflammatory drugs and acetaminophen. Concern about reaching a clinician during off hours and receiving an appropriate evaluation may also contribute, and facilitating follow-up may mitigate these anxieties.

Editor Disclosures at Time of Publication

  • Disclosures for Anna Wald, MD, MPH at time of publication Consultant / Advisory board AiCuris Royalties UpToDate Grant / Research support NIH/National Cancer Institute; NIH/National Institute of Allergy and Infectious Diseases; Genocea Biosciences; Vical Editorial boards Sexually Transmitted Diseases; Sexually Transmitted Infections Leadership positions in professional societies International Society for Sexually Transmitted Diseases Research (Board Member)

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