ASRA Pain Medicine News, May 2023

Development of a Multimodal Pain Management Protocol and Inpatient Consult Service for Parturients Diagnosed with Opioid Use Disorder (OUD) Undergoing Cesarean Delivery

May 12, 2023, 16:22 PM by Michael G. Taylor, MD, and Laura L. Sorabella, MD

Cite as: Taylor M, Sorabella L. Development of a multimodal pain management protocol and inpatient consult service for parturients diagnosed with opioid use disorder (OUD) undergoing cesarean delivery. ASRA Pain Medicine News 2023;48. https://doi.org/10.52211/asra050123.005.


Background

A recent CDC report estimated that the number of women with opioid-related diagnoses at delivery increased an astounding 131% from 2010–2017.1 Buprenorphine is the preferred treatment for opioid use disorder (OUD) in pregnancy, and current guidelines recommend maintaining mothers on buprenorphine throughout their pregnancies and deliveries. Although we’ve optimized post-cesarean analgesia for most women, women on buprenorphine continue to experience severe pain after cesarean delivery. How can we do better to optimize these women’s postoperative experience?

The incidence of OUD in obstetric patients is rising steadily with concomitant increases in the number of parturients presenting for cesarean delivery while receiving medication-assisted treatment with buprenorphine.2 Current guidelines recommend continuing buprenorphine, in addition to counseling and behavioral therapy, throughout pregnancy as it has been shown to lower the risk of preterm birth and result in greater birth weight and larger head circumference.3,4 As a partial mu-opioid receptor agonist, buprenorphine is associated with reduced risks of respiratory depression, sedation, abuse, and overdose. However, studies have shown that buprenorphine does not exhibit a ceiling effect for analgesia, thereby allowing the medication to effectively treat both OUD and postoperative pain.5,6,7 Despite these potential analgesic advantages, buprenorphine’s high receptor binding affinity and long half-life lead to challenges in providing adequate analgesia in women receiving buprenorphine using traditional post-cesarean analgesic protocols.

Chronic opioid use often results in tolerance and opioid-induced hyperalgesia, limiting the efficacy of routine analgesic strategies that rely on opioid medications and necessitating a multimodal analgesic approach.8 Retrospective studies have shown that women maintained on buprenorphine during pregnancy experience higher post-cesarean delivery pain scores and opioid requirements as well as increased difficulty achieving adequate analgesia.9,10 Furthermore, inadequate peripartum pain control is associated with the development of persistent post-cesarean delivery pain, postpartum depression, increased opioid consumption, and patient dissatisfaction.11,12 Achieving adequate analgesia in this patient population is essential.


Buprenorphine’s high receptor binding affinity and long half-life lead to challenges in providing adequate analgesia in women receiving buprenorphine using traditional post-cesarean analgesic protocols.


Objective

Unpublished data (n=214) collected from Vanderbilt University Medical Center from 2010–2020 evaluating pain control in patients receiving buprenorphine at the time of cesarean delivery revealed most patients experienced severe pain with a median numeric rating scale pain score of 7 [interquartile range 6, 8] in the first 24 hours postoperatively. In response to these poor pain outcomes and variability in prescribed postpartum pain control regimens among our anesthesiologists, we standardized a multimodal, evidence-based analgesic plan for this patient population with the goal of improving post-cesarean delivery pain control. To ensure responsiveness to inadequate analgesia, we also established an obstetric anesthesia postoperative pain consult service to manage these patients until hospital discharge.

Description

Our analgesia protocol was developed based upon an extensive literature review, clinical experience, and multidisciplinary discussions with addiction medicine and maternal-fetal medicine. Analgesic options considered for inclusion as well as a summary of supporting literature are presented in Table 1. The final management protocol included the following recommendations:

  • Preoperatively: continue pre-admission buprenorphine dosing, establish patient expectations, and acknowledge their concerns
  • Intraoperatively: administer hydromorphone and/or clonidine as neuraxial medications, consider placing a thoracic epidural or continuing lumbar labor epidural postoperatively, and perform transversus abdominis plane (TAP) or quadratus lumborum (QL) blocks prior to leaving the operating room
  • Postoperatively: conduct daily evaluation by the obstetric anesthesia postoperative pain consult service until hospital discharge, administer scheduled acetaminophen, scheduled ketorolac transitioned to ibuprofen, and oral short-acting opioid agonists as needed with intravenous opioid analgesia as rescue; consider the addition of alternative non-opioid adjuvants

Table 1. Evidence summary on cesarean delivery analgesic options for patients with and without buprenorphine use.

Analgesic Options ConsideredGeneral Cesarean PopulationBuprenorphine-Treated PopulationRationale for Use in Patients on Buprenorphine
Neuraxial Medications
Intrathecal hydromorphoneProvides effective post-cesarean analgesia and patient satisfaction.13No data available.May be preferable to neuraxial morphine given the greater binding affinity at the mu-opioid receptor. Future studies are needed to determine its effectiveness in this population.
Epidural hydromorphoneProvides a similar analgesic effect and side-effect profile compared with epidural morphine.14No data available.May be preferable to neuraxial morphine given the greater binding affinity at the mu-opioid receptor. Future studies are needed to determine its effectiveness in this population.
Intrathecal clonidineProvides effective intraoperative15 and postoperative16 analgesia.No data available.May provide some benefit given activity at non-opioid receptors. Future studies are needed to determine its effectiveness in this population.
Epidural clonidineReduces post-cesarean morphine consumption when combined with epidural fentanyl.17Single case report with several limitations describing modest effectiveness.18May provide some benefit given activity at non-opioid receptors. Future studies are needed to determine its effectiveness in this population.
Regional Anesthesia
Transversus abdominis plane (TAP) blockNo evidence of benefit when combined with neuraxial morphine.19No data available.May be beneficial given possible decreased efficacy of neuraxial opioids with buprenorphine.
Quadratus lumborum blockNo evidence of benefit when combined with or compared to neuraxial morphine.20No data available.May be beneficial given possible decreased efficacy of neuraxial opioids with buprenorphine.
Postoperative lumbar epidural local anesthetic infusionLumbar epidural with bupivacaine and fentanyl provides effective post-cesarean analgesia.21 Lumbar epidural provides better post-cesarean analgesia compared to PCA.22Data from case series suggests possibly effective for post-cesarean analgesia.10May be beneficial in select patients although its use may be limited by impaired mobility.
Postoperative thoracic epidural local anesthetic infusionThoracic epidural with intrathecal morphine provides better post-cesarean analgesia compared to intrathecal morphine alone.23Data from case series suggests possibly effective for post-cesarean analgesia.24 Also allows for unassisted ambulation.May be beneficial in select patients or as a rescue analgesic.
Postoperative Medications
AcetaminophenScheduled acetaminophen results in decreased opioid use after cesarean delivery.25Limited data from case series suggests post-cesarean analgesia benefit as part of a multimodal regimen.10,24Given low risk and low cost, may be beneficial.
KetorolacReduces post-cesarean opioid consumption and pain scores.26Limited data from case series suggests post-cesarean analgesia benefit as part of a multimodal regimen.10,24Given relatively low risk, may be beneficial.
IbuprofenReduces post-cesarean opioid consumption, lowers pain scores, and results in less sedation.27Limited data from case series suggests post-cesarean analgesia benefit as part of a multimodal regimen.10,24Given relatively low risk and low cost, may be beneficial.
GabapentinPerioperative gabapentin does not provide a clinically significant improvement in post-cesarean pain scores.28No data available.Given relatively low risk, may be beneficial.
MemantineNo data available.No data available.May improve acute postoperative analgesia and reduce chronic neuropathic pain.29 May be beneficial and future studies are needed to determine its effectiveness in this population.
Lidocaine patchReduces pain scores compared to placebo in the first 36 hours after cesarean delivery.30No data available.Given low risk and low cost, may be beneficial.
CyclobenzaprineNo data available.No data available.Relieves spasticity and spasms related to musculoskeletal conditions.31 May be beneficial and future studies are needed to determine its effectiveness in this population.
Intravenous patient-controlled analgesiaMorphine PCA is associated with inferior analgesia and higher opioid consumption compared to single-shot epidural morphine.32Several case reports and case series have described effective post-cesarean analgesia with opioid PCA.20,33May be beneficial in patients who do not receive neuraxial analgesia.
Oral opioid agonistsOral opioids may offer superior analgesia with a better side effect profile compared to opioid PCA.34Buprenorphine patients respond to and achieve better analgesia with additional opioid agonists.10,35May be beneficial in addition to multimodal analgesia regimen.

While developing our protocol, we organized numerous multidisciplinary meetings involving leadership from obstetrics, addiction medicine, midwifery, nursing, and obstetric anesthesia to consider the unique challenges presented by patients diagnosed with OUD. Proposed changes we sought to address included daily communication with our obstetric and nursing colleagues regarding the analgesic plan for patients receiving buprenorphine, an emphasis for postpartum nurses to contact our obstetric anesthesia team for pain control concerns, discussion of postpartum patients receiving buprenorphine during daytime safety rounds, and placement of a formal consult order to obstetric anesthesia for billing and reimbursement purposes.

Studies in opioid-naive women have shown that individualized opioid prescriptions following cesarean delivery results in decreased opioid consumption without significant differences in reported pain measures.36,37 An additional study evaluating in-person opioid and analgesic counseling for opioid-naive parturients revealed an enhanced understanding of analgesic strategies, opioid safety, and knowledge retention.38 Hoping to replicate these positive results in our parturients diagnosed with OUD, we felt these women would also benefit from a more personalized care model with a consult service providing individualized evaluation and treatment of their post-cesarean delivery pain.

Initiating an obstetric anesthesia postoperative pain consult service allowed our team to perform daily rounding and assessments as well as optimize post-cesarean delivery analgesia for patients diagnosed with OUD. If analgesia was not well-controlled with the newly standardized regimen, we then recommended and wrote orders for additional medications after a discussion with the obstetric team. Alternative non-opioid adjuncts for pain may include oral gabapentin, oral memantine, and lidocaine patches as well as cyclobenzaprine for muscle stiffness and spasms. As the patients meet their postpartum milestones, we then provide discharge recommendations for pain control to our obstetric colleagues. Any inpatient changes in buprenorphine dosing (eg, more frequent, divided doses to maintain plasma levels) were temporary.

Outcome Measures

We are tracking metrics to ensure that our obstetric anesthesia consult service is positively affecting pain management and the post-cesarean delivery experience of our patients diagnosed with OUD. We are collecting variables concerning opioid consumption, pain scores, type of anesthesia, neuraxial medications administered, and amount and type of non-opioid multimodal medications administered. We are also collecting patient-reported outcome measures using several questions based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey (Figure 1).

Figure 1. Patient-reported outcome measures questions based on the HCAHPS survey.

Overall patient satisfaction with their pain control.
Following cesarean delivery, how often did the obstetric anesthesia team treat you with courtesy and respect?
Following cesarean delivery, how often did the obstetric anesthesia team listen carefully to you in regard to your pain control?
Following cesarean delivery, how often did the obstetric anesthesia team do everything they could to help with your pain control?
Following cesarean delivery, how often was your pain well controlled overall?

Discussion

Despite the increasing prevalence of OUD within the obstetric population, there remains no consensus on the most effective post-cesarean delivery pain control regimen,39 and more studies are needed to identify beneficial pain management strategies. A coordinated, multimodal pharmacotherapy approach is imperative to provide safe, effective care as well as improve patient outcomes and the peripartum experience. We present an obstetric anesthesia pain consult service that uses a standardized multidisciplinary pain management protocol to study the impact of personalized care on postoperative pain management in women diagnosed with OUD that could be easily replicated at other interested institutions.


Michael Taylor
Michael G. Taylor, MD, is a clinical assistant professor at the University of Michigan in Ann Arbor.

Laura Sorabella
Laura L. Sorabella, MD, is an assistant professor in the Department of Anesthesiology at Vanderbilt University Medical Center in Nashville, TN. 

References

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