A personalized protocol for prescribing opioids after cesarean delivery: leveraging the electronic medical record to reduce outpatient opioid prescriptions

Abstract

Though cesarean delivery is the most common surgery performed in the United States, prescribing practices for analgesia vary. Strategies to manage postpartum pain have mostly focused on the immediate postpartum period when patients are still admitted to the hospital. At discharge, most providers prescribe a fixed number of opioid tablets. Most patients do not use all the opioids they are prescribed at hospital discharge. This leads to an excess of opioids in the community which can ultimately lead to misuse and diversion. To determine if a transition from universal opioid prescribing to a personalized, patient specific protocol decreases morphine equivalents prescribed at hospital discharge after cesarean delivery, while adequately controlling pain. This is a prospective cohort study of patients undergoing cesarean delivery before and after implementation of a personalized opioid prescribing practice at time of hospital discharge. Each patient was prescribed scheduled ibuprofen and acetaminophen, with a prescription for oxycodone tablets equal to 5 times the morphine equivalents used in the 24 hours prior to discharge, calculated via an electronic order set. The prior traditional cohort were routinely prescribed 30 tablets of acetaminophen-codeine 300-30 milligrams. The primary outcome was morphine equivalents prescribed at discharge. A hotline to address pain control issues after discharge was established, and calls, emergency room visits, and re-admissions were examined. Statistical analyses included chi-square and Wilcoxon rank-sum with a P-value < 0.05 considered statistically significant. 412 patients underwent cesarean delivery in the 6 weeks after initiation of the personalized prescribing protocol and were compared to 367 patients prior to the change. The median morphine equivalents prescribed at discharge was lower with personalized prescribing (37.5 [1st quartile 0, 3rd quartile 75] vs 135 [135, 135], P < 0.001). 176 (43%) patients were not prescribed opioids at discharge which was a substantial change as all 367 patients in the traditional cohort received opioids at discharge (P < 0.001). Nine hotline phone calls were received; none required additional opioids after a 24 hour trial of scheduled ibuprofen, which none had taken prior to the call. 11 (2.7%) patients presented to the emergency room for pain evaluation, of which none required re-admission or an outpatient prescription of opioids. A personalized protocol for opioid prescriptions after cesarean delivery decreased total morphine equivalents and number of opioid tablets at discharge, without hospital re-admissions or need for rescue opioid prescriptions after discharge. Opioids released into our community will be reduced by over 90,000 tablets per year, without demonstrable adverse effect.