Lower post-C-section opioid scrips means far fewer unused pills in the Toronto community: study

A quality improvement initiative to reduce the number of opioids routinely prescribed at hospital discharge following a C-section translated into a 43% overall decrease in opioid prescriptions compared to the previous year. All evidence suggested that patients’ pain was adequately controlled despite fewer opioid prescriptions sent home. “This has dramatically reduced the amount of opioids that we give out, and hopefully there is less excess in the community that can be diverted to misuse,” said Dr. Amanda Selk, senior author of the study and an obstetrician at Mount Sinai Hospital in Toronto. Dr. Selk and colleagues designed a quality improvement program at Mount Sinai Hospital, where 2,500 C-sections are performed each year. The standard practice was to give patients 20 hydromorphone tablets (1 mg) at hospital discharge following a C-section. Acetaminophen and a NSAID was also prescribed. A previous small study by Dr. Selk and Dr. Shira Gold and colleagues found that many women did not use the opioids prescribed post-C-section. The unused pills ended up sitting in medicine cabinets and bathrooms. In follow-up phone calls, the patients reported good pain control. “You can see that there was a lot of extra given and a lot that stayed in the community,” Dr. Selk said. “It made me think we didn’t actually need to give them to everybody, but it is hard to change practice,” she said. “A lot of people worry that their patients will be in pain, and you don’t want to undertreat pain.” Read: New online resource to help patients make informed decisions on next birth after C-section The quality improvement intervention ran from January to June 2019 and involved: Resident education advising them not to routinely prescribe opioids; Postpartum nursing education about pain management after discharge; Posters with guidance on how to discuss opioids with patients; Patient education materials about pain management after discharge; Electronic discharge prescriptions replaced paper prescriptions. If opioids were prescribed, only 10 hydromorphone tablets (1 mg) were prescribed. Non-opioid analgesics prescribed were 28 tablets of acetaminophen (500 mg) and 14 tablets of naproxen (500 mg). Dr. Selk and colleagues studied 1,352 patients who had a C-section between July and December 2018, prior to the quality improvement initiative, and 1, 226 patients who had a C-section a year later, after the initiative. Overall, the percentage of patients who received an opioid prescription at discharge decreased from 97.6% to 53.9%. When the amount of opioids prescribed was translated into morphine milliequivalents (MME), the initiative was associated with a decrease of 61.7 MME prescribed. There were no visits to the postnatal assessment unit for pain control and obstetricians reported no visits or enquiries regarding pain management. After the initiative, opioids prescribed at discharge was associated with whether or not opioids were given for pain while the patient was in hospital. Dr. Selk said the results suggest a change in culture, and wondered this patient-centred and individualized approach to prescribing opioids could be used in other surgical areas. “It is important for us not to assume patients are going to need these medications,” said Dr. Sebastian Hobson. Instead, discharge medications should match the level of pain that the patient is experiencing, he said. Dr. Hobson is a maternal-fetal medicine physician at Mount Sinai Hospital in Toronto and the co-chair of the clinical practice obstetrics committee with the Society of Obstetricians and Gynecologists of Canada (SOGC). He was asked to comment on the study by the Medical Post. Read: Study co-author says planned C-sections may be less risky for some moms and babies Dr. Selk said a quality improvement initiative needs to have a multi-faceted approach, so all stakeholders understand why it’s being done and how to do it. The Mount Sinai Hospital initiative focused on staff who were in charge of discharge and prescriptions at discharge. “We worked at resident-level, nursing-level and patient-level,” she said. Some fellows and attending physicians were also involved. After the intervention, first-year residents and fellows prescribed the least amount of opioids at discharge post C-section, while attending physicians prescribed the most. Dr. Selk said this is important, because these residents will go on to teach other physicians, and many physicians continue to practice the way they were trained. This one quality improvement initiative could go on to impact practice elsewhere. Both Dr. Hobson and Dr. Selk didn’t know of similar initiatives in other Canadian hospitals. “It has not been studied yet but this is a good opportunity for us to study this,” Dr. Hobson said. There are currently no Canadian guidelines on the management of pain post-C-section. “I think a lot of work can be done on postpartum prescribing,” Dr. Selk said. “Developing more of a standardized approach to pain management across the country would be useful.” The American College of Obstetricians and Gynecologists released a clinical consensus statement about pharmacological management of postpartum pain in September 2021. The statement reads that eliminating routine opioid ordering could bring decreased opioid consumption without compromising pain control. The study was published in the Canadian Journal of Anesthesia. Read: Alberta offers free, same-day Sublocade access as overdoses rise

Lower post-C-section opioid scrips means far fewer unused pills in the Toronto community: study

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