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.

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.

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 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. 

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