Opioid-sparing Approach to Pain Post-Cesarean Section

TEAGAN MCCARTHY, BS

Sidney Kimmel Medical College at Thomas Jefferson University

SUMMARY POINTS 

• There are 1.2 million cesarean sections performed each year on average, accounting for ⅓ of all deliveries in the United States.  

• Opioids are routinely over-prescribed for these procedures, giving communities access to up to 20 million unused opioids. 

• Abdominal wall nerve blocks, acetaminophen, and NSAIDs can all reduce opioid consumption following Cesarean section procedures. 

• Multimodal approaches to post-labor pain that take patient characteristics into account need to be explored in response to the opioid epidemic. 

ANALYSIS

Background

In the United States, labor and delivery is the most common cause of hospitalization (1). 1.2 million Cesarean sections are performed each year, accounting for roughly one-third of all deliveries (2). Opioids are routinely prescribed following these procedures but current practices fall short of good stewardship. One multisite survey found that women had an average of 16 pills leftover after recovery (3). Another study found a difference of 14 pills between the average prescribed and consumed (4). In both studies, most women reported not properly storing or disposing of leftover pills. These numbers indicate there could be nearly 20 million accessible opioids from C. sections alone (3). Efforts to reduce the gap between prescription and consumption is relevant to combating the opioid crisis given high rates of diversion, with the most common source of drugs for non-medical use being family and friends (5). Patients themselves are also at risk for misuse. Studies show that anywhere from 0.12% to 2.2% of women become persistent opioid users post-C. section (6). Although the definition of “persistent user” varies, it generally involves filling two or more prescriptions within the first postoperative year. Predictors of opioid use following C. section include a history of illicit substance, antidepressant, or tobacco use, other pain conditions, and in-hospital opioid consumption (7, 8).

While opioid use comes with its own harms, improper management of post-delivery pain has a negative impact on both mother and baby. It can contribute to chronic pain, postpartum depression, and breastfeeding difficulty among other obstacles (8). Thus, it is vital to explore options that can adequately control pain while limiting the negative effects of opioid use. Interestingly, the amount of opioids dispensed post-Cesarean has a positive association with the amount of pills consumed but does not correlate with patient satisfaction (3,4,8). This indicates that opioid-sparing approaches may limit opioid consumption without worsening patient outcomes. 

Analysis

According to the Procedure-Specific Pain Management (PROSPECT) recommendations for elective Cesareans under neuraxial anesthesia, intrathecal morphine or diamorphine should be given preoperatively while postoperative pain should be managed with acetaminophen and NSAIDs, reserving opioids only for rescue analgesia (9). These guidelines also indicate that abdominal wall nerve blocks can limit the need for postoperative opioids and act as a substitute for preoperative morphine (9). Trials of quadratus lumborum (QL) blocks have found that they reduce opioid consumption and pain scores following C. section and are equally if not more effective than intrathecal morphine (Figure 1) (10,11,12). The success of the approach depends on spread of the anesthetic into the paravertebral space which may allow for extended relief of visceral pain (11). Transversus abdominis plane (TAP) blocks have also been shown to be effective, however some data indicates that the effects are limited to somatic pain. Although total analgesia required after the two block types is similar, TAP blocks are less effective at reducing morphine consumption (11,13). More research is needed to determine which block technique is superior. 

Figure 1. Integrated Analgesia Scores (IAS) at rest (A) and movement (B) over a 48-hour period in patients that received quadratus lumborum block (QLB), intrathecal morphine (ITM), or saline control. SEE ARTICLE from Salama ER. Ultrasound-guided bilateral quadratus lumborum block vs. intrathecal morphine for postoperative analgesia after cesarean section: a randomized controlled trial. Korean Journal of Anesthesiology. 2020;73(2):121-128. 10.4097/kja.d.18.00269. 

In addition to nerve blocks, the effectiveness of acetaminophen has been explored. One trial found that preoperative intravenous acetaminophen had no effect on postoperative opioid use or pain when compared to placebo (14). These results differ from another trial which found decreased pain scores and morphine use in the first postoperative day, indicating that more research is needed to make a definitive assessment of preoperative acetaminophen alone (15). A third trial in which acetaminophen was continued into the postoperative period saw a reduction in opioid consumption, which points to the potential need for the medication both before and after surgery (16).   

Like other approaches in the PROSPECT guidelines, NSAIDs have also been associated with reduced pain scores and opioid consumption following C. section (17). One study comparing intramuscular piroxicam to tramadol even demonstrated that the NSAID was more effective than the opioid at reducing pain scores up to 8 hours post-op and provided greater patient satisfaction overall (18). Despite the known effectiveness of these drugs, little research has been conducted to determine which NSAIDs are best for post-Cesarean pain. One meta-analysis found few differences amongst the drug class but suggested indomethacin may be better than selective COX-2 inhibitors at  reducing pain scores, potentially due to its effects on the endocannabinoid system (19). It is important to note, however, many of the studies involved in this meta-analysis included a low quality of evidence.

In general, when it comes to limiting opioid use following surgery, multimodal approaches should be employed. In resource-limited settings, approaches as simple as combining NSAIDs with opioids were better at reducing postoperative pain than opioids alone (20). These multimodal approaches should not be limited to drugs. One successful post-C. section comfort approach included gum chewing, abdominal binders, and education for both patient and provider in addition to non-opioid analgesics. Implementation of this approach led to a 61% reduction in morphine milliequivalents consumed and a 70.4% increase in the number of patients receiving less than 20 pills at discharge (21). Further research needs to be done to further individualize these approaches based on patient needs. 

Discussion 

Research shows there are a variety of non-opioid approaches to mitigate pain post-Cesarean section. For best results, more research is needed to optimize nerve block technique, NSAID use, and timing of acetaminophen doses. When opioid prescriptions are required, predictors such as pre-discharge opioid consumption should be considered to limit the amount of pills leftover. Efforts also need to be made to involve patients by educating them on pain management including appropriate expectations, opioid alternatives, and proper pill storage. Moving forward, different multimodal approaches that include drug and non-drug interventions, educational components, and the potential to be customized on a patient-by-patient basis should be explored. 

REFERENCES: 

1. Mills JR, Huizinga MM, Robinson SB, Lamprecht L, Handler A, Petros M, Davis T, and Chan K. Draft opioid-prescribing guidelines for uncomplicated normal spontaneous vaginal birth. Obstetrics & Gynecology. 2019;133(1):81-90. 10.1097/AOG.0000000000002996 

2. Center for Disease Control and Prevention. Method of delivery. National Center For Health Statistics. 2023. Accessed June 28, 2023. https://www.cdc.gov/nchs/fastats/delivery.htm 

3. Bateman BT, Cole NM, Maeda A, Burns SM, Houle TT, Huybrechts KF, Clancy CR, Hopp SB, Ecker JL, Ende H, Grewe K, Corradini BR, Schoenfeld RE, Sankar K, Day LJ, Harris LC,  Booth JL, Flood P, Bauer ME, Tsen LC, Leffert LR, and Landau R. Patterns of opioid prescription and use after cesarean delivery. Obstetrics & Gynecology.  2017;130(1):29-35. 10.1097/AOG.0000000000002093 

4. Avalos C. Razzolini GD, Crimmins S, and Mark K. Opioid prescription-use after cesarean delivery: an observational cohort study. Journal of Anesthesia. 2021;35:617-624. https://doi.org/10.1007/s00540-021-02959-z 

5. Hulme S, Bright D, and Nielsen S. The source and diversion of pharmaceutical drugs for non-medical use: a systematic review and meta-analysis. Drug and Alcohol Dependence. 2018;186:242-256. https://doi.org/10.1016/j.drugalcdep.2018.02.010 

6. Landau R, Cavanaugh PF, and DiGiorgi M. Persistent opioid use after cesarean delivery in the United States of America: a systematic review. International Journal of Obstetric Anesthesia. 2023;54(103644). https://doi.org/10.1016/j.ijoa.2023.103644 

7. Bateman BT, Franklin JM, Bykov K, Shrank WH, Brennan TA, Landon JE, Pathmell JP, Huybrechts KF, Fischer MA, and Choudhry NK. Persistent opioid use following cesarean delivery: patterns and predictors among opioid naïve women. American Journal of Obstetrics and Gynecology. 2016;215(3):353.e1-353.e18. 10.1016/j.ajog.2016.03.016

8. Carrico JA, Mahoney K, Raymond KM, McWilliams SK, Mayes LM, Mikulich-Gilbertson SK, and Bartels K. Predicting opioid use following discharge after cesarean delivery. Annals of Family Medicine. 2020;18(2):118-126. 10.1370/afm.2493 

9. Roofthooft E, Joshi GP, Rawal N, and Van de Velde M. PROSPECT guideline for elective cesarean section: updated systematic review and procedure-specific postoperative pain management recommendations. Anesthesia. 2020;76(5):665-680. https://doi.org/10.1111/anae.15339 

10. Hansen CK, Dam M, Steingrimsdottiir GE, Laier GH, Lebech M, Poulsen TD, Chan VWS, Wolmarans M, Bendsten TF, and Borglum J. Ultrasound-guided transmuscular quadratus lumborum block for elective cesarean section significantly reduces postoperative opioid consumption and prolongs time to first opioid request: a double-blind randomized trial. Regional Anesthesia & Pain Medicine. 2019;44:896-900. http://orcid.org/0000-0002-1719-9402 

11. Blanco R, Ansari T, and Girgis E. Quadratus lumborum block for postoperative pain after cesarean section: a randomized controlled trial. European Journal of Anesthesiology. 2015;32(11):812-818. 10.1097/EJA.0000000000000299

12. Salama ER. Ultrasound-guided bilateral quadratus lumborum block vs. intrathecal morphine for postoperative analgesia after cesarean section: a randomized controlled trial. Korean Journal of Anesthesiology. 2020;73(2):121-128. 10.4097/kja.d.18.00269

13. Borys M, Potrec-Studzinska B, Kutnik P, Sysiak-Slawecka J, Rypulak E, Geca T, Kwasniewska A, Czuczwar M, and Piwowarczyk P. The effectiveness of transversus abdominis plane and quadratus lumborum blocks in acute postoperative pain following cesarean section- a randomized, single-blind, controlled trial. International Journal of Environmental Research and Public Health. 2021;18(13):7034. 10.3390/ijerph18137034 

14. Towers CV, Shelton S, van Nes J, Gregory E, Liske E, Smalley A, Mobley E, Faircloth B, and Fortner KB. Preoperative cesarean delivery intravenous acetaminophen treatment for postoperative pain control: a randomized double-blinded placebo control trial. American Journal of Obstetrics and Gynecology. 2018;218(3):353.e1-353.e4. https://doi.org/10.1016/j.ajog.2017.12.203 

15. Ozmete O, Bali C, Cok OY, Ergenoglu P, Ozyilkan NB, Akin S, Kalayci H, and Aribogan A. Preoperative paracetamol improves post-cesarean delivery pain management: a prospective, randomized, double-blind, placebo-controlled trial. Journal of Clinical Anesthesia. 2016;33:51-57. https://doi.org/10.1016/j.jclinane.2016.02.030 

16. Altenau B, Crisp CC, Devaiah CG,  and Lambers DS. Randomized controlled trial of intravenous acetaminophen for postcesarean delivery pain control. American Journal of Obstetrics and Gynecology. 2017;217(3):362.e1-362.e6.. https://doi.org/10.1016/j.ajog.2017.04.030 

17. Zeng AM, Nami NF, Wu CL, and Murphy JD. The analgesic efficacy of NSAIDs in patients undergoing cesarean deliveries: a meta-analysis. Regional Anesthesia & Pain Medicine. 2016;41:763-772. http://dx.doi.org/10.1097/AAP.0000000000000460 

18. Thippeswamy T, Krishnaswamy B, Bengalorkar GM, and Mariyappa N. Comparison of efficacy and safety of intramuscular piroxicam and tramadol for post-operative pain in patients undergoing cesarean delivery. Journal of Clinical and Diagnostic Research. 2016;10(11):FC01-FC04. 10.7860/JCDR/2016/21861.8785 

19. Murdoch I, Carver A, O’Carroll J, Blake L, Carvalho B, Onwochei DN, and Desai N. Comparison of different nonsteroidal anti-inflammatory drugs for cesarean section: a systematic review and network meta-analysis. Korean Journal of Anesthesiology. 2023.  https://doi.org/10.4097/kja.23014 

20. Adeniji AO & Atanda OOA. Randomized comparison of effectiveness of unimodal opioid analgesia with multimodal analgesia in post-cesarean section pain management. Journal of Pain Research. 2013:6:419-424. 10.2147/JPR.S44819 

21. Burgess, A, Harris A, Wheeling J, and Dermo R. A quality improvement initiative to reduce opioid consumption after cesarean birth. The American Journal of Maternal?Child Nursing. 2019;44(5):250-259. 10.1097/NMC.0000000000000549