Development of a Multimodal Pain Management Protocol and Inpatient Consult Service for Parturients Diagnosed with Opioid Use Disorder (OUD) Undergoing Cesarean Delivery
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.
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.
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.
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 Considered||General Cesarean Population||Buprenorphine-Treated Population||Rationale for Use in Patients on Buprenorphine|
|Intrathecal hydromorphone||Provides effective post-cesarean analgesia and patient satisfaction.13||No 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 hydromorphone||Provides a similar analgesic effect and side-effect profile compared with epidural morphine.14||No 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 clonidine||Provides 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 clonidine||Reduces post-cesarean morphine consumption when combined with epidural fentanyl.17||Single case report with several limitations describing modest effectiveness.18||May provide some benefit given activity at non-opioid receptors. Future studies are needed to determine its effectiveness in this population.|
|Transversus abdominis plane (TAP) block||No evidence of benefit when combined with neuraxial morphine.19||No data available.||May be beneficial given possible decreased efficacy of neuraxial opioids with buprenorphine.|
|Quadratus lumborum block||No evidence of benefit when combined with or compared to neuraxial morphine.20||No data available.||May be beneficial given possible decreased efficacy of neuraxial opioids with buprenorphine.|
|Postoperative lumbar epidural local anesthetic infusion||Lumbar epidural with bupivacaine and fentanyl provides effective post-cesarean analgesia.21 Lumbar epidural provides better post-cesarean analgesia compared to PCA.22||Data from case series suggests possibly effective for post-cesarean analgesia.10||May be beneficial in select patients although its use may be limited by impaired mobility.|
|Postoperative thoracic epidural local anesthetic infusion||Thoracic epidural with intrathecal morphine provides better post-cesarean analgesia compared to intrathecal morphine alone.23||Data 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.|
|Acetaminophen||Scheduled acetaminophen results in decreased opioid use after cesarean delivery.25||Limited data from case series suggests post-cesarean analgesia benefit as part of a multimodal regimen.10,24||Given low risk and low cost, may be beneficial.|
|Ketorolac||Reduces post-cesarean opioid consumption and pain scores.26||Limited data from case series suggests post-cesarean analgesia benefit as part of a multimodal regimen.10,24||Given relatively low risk, may be beneficial.|
|Ibuprofen||Reduces post-cesarean opioid consumption, lowers pain scores, and results in less sedation.27||Limited data from case series suggests post-cesarean analgesia benefit as part of a multimodal regimen.10,24||Given relatively low risk and low cost, may be beneficial.|
|Gabapentin||Perioperative gabapentin does not provide a clinically significant improvement in post-cesarean pain scores.28||No data available.||Given relatively low risk, may be beneficial.|
|Memantine||No 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 patch||Reduces pain scores compared to placebo in the first 36 hours after cesarean delivery.30||No data available.||Given low risk and low cost, may be beneficial.|
|Cyclobenzaprine||No 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 analgesia||Morphine PCA is associated with inferior analgesia and higher opioid consumption compared to single-shot epidural morphine.32||Several case reports and case series have described effective post-cesarean analgesia with opioid PCA.20,33||May be beneficial in patients who do not receive neuraxial analgesia.|
|Oral opioid agonists||Oral opioids may offer superior analgesia with a better side effect profile compared to opioid PCA.34||Buprenorphine patients respond to and achieve better analgesia with additional opioid agonists.10,35||May 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.
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?|
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 G. Taylor, MD, is a clinical assistant professor at the University of Michigan in Ann Arbor.
Laura L. Sorabella, MD, is an assistant professor in the Department of Anesthesiology at Vanderbilt University Medical Center in Nashville, TN.
- Hirai AH, Ko JY, Owens PL, et al. Neonatal abstinence syndrome and maternal opioid-related diagnoses in the US, 2010-2017. JAMA 2021;325(2):146–55. https://doi.org/10.1001/jama.2020.24991
- Maeda A, Bateman BT, Clancy CR, et al. Opioid abuse and dependence during pregnancy: temporal trends and obstetrical outcomes. Anesthesiology 2014;121(6):1158-65. https://doi.org/1097/ALN.0000000000000472
- Committee Opinion No. 711: Opioid use and opioid use disorder in pregnancy. Obstet Gynecol 2017;130(2):e81-e94. https://doi.org/10.1097/AOG.0000000000002235
- Zedler BK, Mann AL, Kim MM, et al. Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child. Addiction 2016;111(12):2115-28. https://doi.org/10.1111/add.13462
- Dahan A, Yassen A, Romberg R, et al. Buprenorphine induces ceiling in respiratory depression but not in analgesia. Br J Anaesth 2006;96(5):627-32. https://doi.org/10.1093/bja/ael051
- Raffa RB, Haidery M, Huang HM, et al. The clinical analgesic efficacy of buprenorphine. J Clin Pharm Ther 2014;39(6):577-83. https://doi.org/10.1111/jcpt.12196
- Richardson MG, Raymond BL. Lack of evidence for ceiling effect for buprenorphine analgesia in humans. Anesth Analg 2018;127(1):310-11. https://doi.org/10.1213/ANE.0000000000003368
- Young JL, Lockhart EM, Baysinger CL. Anesthetic and obstetric management of the opioid dependent parturient. Int Anesthesiol Clin 2014;52(2):67-85. https://doi.org/10.1097/AIA.0000000000000011
- Meyer M, Paranya G, Norris AK, Howard D. Intrapartum and postpartum analgesia for women maintained on buprenorphine during pregnancy. Eur J Pain 2010;14(9):939-43. https://doi.org/10.1016/j.ejpain.2010.03.002
- Tith S, Bining G, Bollag L. Management of eight labor and delivery patients dependent on buprenorphine (SubutexTM): a retrospective chart review. F1000Res 2018;7:7. https://doi.org/10.12688/f1000research.13350.2
- Eisenach JC, Pan PH, Smiley R, et al. Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression. Pain 2008;140(1):87-94. https://doi.org/10.1016/j.pain.2008.07.011
- Moriyama K, Ohashi Y, Motoyasu A, et al. Intrathecal administration of morphine decreases persistent pain after cesarean section: a prospective observational study. PLoS One 2016;11(5):e0155115. https://doi.org/10.1371/journal.pone.0155114
- Sviggum HP, Arendt KW, Jacob AK, et al. Intrathecal hydromorphone and morphine for postcesarean delivery analgesia: determination of the ED90 using a sequential allocation biased-coin method. Anesth Analg 2016;123(3):690-97. https://doi.org/10.1213/ANE.0000000000001229
- Marroquin B, Feng C, Balofsky A, et al. Neuraxial opioids for post-cesarean delivery analgesia: can hydromorphone replace morphine? A retrospective study. Int J Obstet Anesth 2017;30:16-22. https://doi.org/10.1016/j.ijoa.2016.12.008
- Benhamou D, Thorin D, Brichant JF, et al. Intrathecal clonidine and fentanyl with hyperbaric bupivacaine improves analgesia during cesarean section. Anesth Analg 1998;87(3):609-13. https://doi.org/10.1097/00000539-199809000-00022
- Paech MJ, Pavy TJG, Orlikowski CEP, et al. Postcesarean analgesia with spinal morphine, clonidine, or their combination. Anesth Analg 2004;98(5):1460-6. https://doi.org/10.1213/01.ane.0000111208.08867.3c
- Eisenach JC, D’Angelo R, Taylor C, Hood DD. An isobolographic study of epidural clonidine and fentanyl after cesarean section. Anesth Analg 1994;79(2):285-90. https://doi.org/10.1213/00000539-199408000-00014
- Hoyt MR, Shah U, Cooley J, Temple M. Use of epidural clonidine for the management of analgesia in the opioid addicted parturient on buprenorphine maintenance therapy: an observational study. Int J Obstet Anesth 2018;34:67-72. https://doi.org/10.1016/j.ijoa.2018.01.001
- Mishriky BM, George RB, Habib AS. Transversus abdominis plane block for analgesia after cesarean delivery: a systematic review and meta-analysis. Can J Anaesth 2012;59(8):766-78. https://doi.org/1007/s12630-012-9729-1
- Hussain N, Brull R, Weaver T, et al. Postoperative analgesic effectiveness of quadratus lumborum block for cesarean delivery under spinal anesthesia. Anesthesiology 2021;134(1):72-87. https://doi.org/10.1097/ALN.0000000000003611
- Cooper DW, Ryall DM, McHardy FE, et al. Patient-controlled extradural analgesia with bupivacaine, fentanyl, or a mixture of both, after caesarean section. Br J Anaesth 1996;76(5):611-15. https://doi.org/10.1093/bja/76.5.611
- Woods AB, Crist B, Kowalewski S, et al. A cross-sectional analysis of the effect of patient-controlled epidural analgesia versus patient controlled analgesia on postcesarean pain and breastfeeding. J Obstet Gynecol Neonatal Nurs 2012;41(3):339-46. https://doi.org/10.1111/j.1552-6909.2012.01370.x
- Sato I, Iwasaki H, Luthe SK, et al. Comparison of intrathecal morphine with continuous patient-controlled epidural anesthesia versus intrathecal morphine alone for post-cesarean section analgesia: a randomized controlled trial. BMC Anesthesiol 2020;20(1):138. https://doi.org/10.1186/s12871-020-01050-6
- Leighton BL, Crock LW. Case series of successful postoperative pain management in buprenorphine maintenance therapy patients. Anesth Analg 2017;125(5):1779-83. https://doi.org/10.1213/ANE.0000000000002498
- Valentine AR, Carvalho B, Lazo TA, Riley ET. Scheduled acetaminophen with as-needed opioids compared to as-needed acetaminophen plus opioids for post-cesarean pain management. Int J Obstet Anesth 2015;24(3):210-16. https://doi.org/10.1016/j.ijoa.2015.03.006
- Lowder JL, Shackelford DP, Holbert D, Beste TM. A randomized, controlled trial to compare ketorolac tromethamine versus placebo after cesarean section to reduce pain and narcotic usage. Am J Obstet Gynecol 2003;189(6):1559-62. https://doi.org/10.1016/j.ajog.2003.08.014
- Zeng AM, Nami NF, Wu CL, Murphy JD. The analgesic efficacy of nonsteroidal anti-inflammatory agents (NSAIDs) in patients undergoing cesarean deliveries: a meta-analysis. Reg Anesth Pain Med 2016;41(6):763-72. https://doi.org/10.1097/AAP.0000000000000460
- Monks DT, Hoppe DW, Downey K, et al. A perioperative course of gabapentin does not produce a clinically meaningful improvement in analgesia after cesarean delivery: a randomized controlled trial. Anesthesiology 2015;123(2):320-26. https://doi.org/10.1097/ALN.0000000000000722
- Suzuki M. Role of N-methyl-D-aspartate receptor antagonists in postoperative pain management. Curr Opin Anaesthesiol 2009;22(5):618-22. https://doi.org/10.1097/ACO.0b013e32832e7af6
- Queiroz VKP, Marinho AMN, Barros GAM. Analgesic effects of a 5% lidocaine patch after cesarean section: a randomized placebo-controlled double-blind clinical trial. J Clin Anesth 2021;73:110328 https://doi.org/10.1016/j.jclinane.2021.110328
- Kaye AD, Granier AL, Garcia AJ, et al. Non-opioid perioperative pain strategies for the clinician: a narrative review. Pain Ther 2020;9:(1)25-39. https://doi.org/10.1007/s40122-019-00146-3
- Rapp-Zingraff N, Bayoumeu F, Baka N, et al. Analgesia after caesarean section: patient-controlled intravenous morphine vs epidural morphine. Int J Obstet Anesth 1997;6(2):87-92. https://doi.org/10.1016/s0959-289x(97)80003-9
- Jones HE, Johnson RE, Milio L. Post-cesarean pain management of patients maintained on methadone or buprenorphine. Am J Addict 2006;15(3):258-259. https://doi.org/10.1080/10550490600626721
- Davis KM, Esposito MA, Meyer BA. Oral analgesia compared with intravenous patient-controlled analgesia for pain after cesarean delivery: a randomized controlled trial. Am J Obstet Gynecol 2006;194(4):967-71. https://doi.org/10.1016/j.ajog.2006.02.025
- Jones HE, O’Grady K, Dahne J, et al. Management of acute postpartum pain in patients maintained on methadone or buprenorphine during pregnancy. Am J Drug Alcohol Abuse 2009;35(3):151-56. https://doi.org/10.1080/00952990902825413
- Osmundson SS, Raymond BL, Kook BT, et al. Individualized compared with standard post-discharge oxycodone prescribing after cesarean birth: a randomized controlled trial. Obstet Gynecol 2018;132(3):624-30. https://doi.org/10.1097/AOG.0000000000002782
- Prabhu M, McQuaid-Hanson E, Hopp S, et al. A shared decision-making intervention to guide opioid prescribing after cesarean delivery. Obstet Gynecol 2017;130(1):42-6. https://doi.org/10.1097/AOG.0000000000002094
- Lam L, Richardson MG, Zhao Z, et al. Enhanced discharge counseling to reduce outpatient opioid use after cesarean delivery: a randomized clinical trial. Am J Obstet Gynecol MFM 2021;3:100286. https://doi.org/10.1016/j.ajogmf.2020.100286
- Raymond BL, Kook BT, Richardson MG. The opioid epidemic and pregnancy: implications for anesthetic care. Curr Opin Anaesthesiol 2018;31(3):243-50. https://doi.org/10.1097/ACO.0000000000000590