151 Landau R, et al. Reg Anesth Pain Med 2021;46:151–156. doi:10.1136/rapm-2020-102007 Original research Effect of a stepwise opioid-sparing analgesic protocol on in-hospital oxycodone use and discharge prescription after cesarean delivery Ruth Landau, 1 Erik Romanelli, 2 Bahaa Daoud, 1 Ben Shatil, 3 Xiwen Zheng, 1 Beatrice Corradini, 1 Janice Aubey, 1 Caroline Wu, 1 Catherine Ha, 1 Jean Guglielminotti 1 To cite: Landau R, Romanelli E, Daoud B, et al. Reg Anesth Pain Med 2021;46:151–156. ► Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ rapm-2020-102007). 1 Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA 2 Anesthesiology, Montefore Medical Center, Bronx, New York, USA 3 Anesthesiology, Emory University, Atlanta, Georgia, USA Correspondence to Dr Jean Guglielminotti, Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA; jg3481@cumc.columbia.edu Received 7 August 2020 Revised 18 September 2020 Accepted 8 October 2020 Published Online First 10 November 2020 © American Society of Regional Anesthesia & Pain Medicine 2021. No commercial re-use. See rights and permissions. Published by BMJ. ABSTRACT Introduction Opioid exposure during hospitalization for cesarean delivery increases the risk of new persistent opioid use. We studied the effectiveness of stepwise multimodal opioid-sparing analgesia in reducing oxycodone use during cesarean delivery hospitalization and prescriptions at discharge. Methods This retrospective cohort study analyzed electronic health records of consecutive cesarean delivery cases in four academic hospitals in a large metropolitan area, before and after implementation of a stepwise multimodal opioid-sparing analgesic computerized order set coupled with provider education. The primary outcome was the proportion of women not using any oxycodone during in-hospital stay (’non-oxycodone user’). In-hospital secondary outcomes were: (1) total in-hospital oxycodone dose among users, and (2) time to frst oxycodone pill. Discharge secondary outcomes were: (1) proportion of oxycodone-free discharge prescription, and (2) number of oxycodone pills prescribed. Results The intervention was associated with a signifcant increase in the proportion of non-oxycodone users from 15% to 32% (17% difference; 95% CI 10 to 25), a decrease in total in-hospital oxycodone dose among users, and no change in the time to frst oxycodone dose. The adjusted OR for being a non- oxycodone user associated with the intervention was 2.67 (95% CI 2.12 to 3.50). With the intervention, the proportion of oxycodone-free discharge prescription increased from 4.4% to 8.5% (4.1% difference; 95% CI 2.5 to 5.6) and the number of prescribed oxycodone pills decreased from 30 to 18 (−12 pills difference; 95% CI −11 to −13). Conclusions Multimodal stepwise analgesia after cesarean delivery increases the proportion of oxycodone- free women during in-hospital stay and at discharge. INTRODUCTION Opioid use and abuse during pregnancy and the post partum has increased fivefold in the USA between 1999 and 2014. 1 2 Meanwhile, pregnancy- associated mortality involving opioids has more than tripled from 1.3 per 100 000 in 2007 to 4.2 in 2016. 3 From a public health perspective, it is particularly alarming since childbirth is the most common indication for hospitalization nationwide with about 4 million annual births, and cesarean delivery being the most performed inpatient proce- dure with about 1.3 million annual cases. 4 Opioid exposure during in-hospital stay after cesarean delivery may contribute to the observed increase in opioid use and opioid-related deaths. The incidence of persistent opioid use among opioid-naïve women after a hospitalization for cesarean delivery varies but can be as high as 2.2% (1 per 50), 5–8 and that of an opioid overdose 0.9 per 100 000. 9 The likelihood for new persistent opioid use increases with each additional day of opioid medication supplied as of the third day, 10 11 which underscores that persistent opioid use can be triggered by the initial postpartum opioid exposure. The American College of Obstetricians and Gyne- cologists (ACOG) therefore recommended in 2018 to limit the ‘duration of use of opiate prescriptions (after childbirth) to the shortest reasonable course expected for treating acute pain’. 12 Multimodal stepwise protocols are currently recommended for in-hospital and postdischarge analgesia after cesarean delivery; they should include intraoperative neuraxial opioids given at the time of anesthesia, scheduled postoperative non-opioid medications, and rescue postoperative systemic opioids. 12 Discharge opioid prescription should also take into account intrahospital opioid consumption. 13 However, the three premises that non-opioid analgesic medications should be admin- istered in a scheduled manner regardless of the pain score intensity, that opioids should be offered only if and when the patient experiences severe breakthrough pain, and that discharge prescription should be individualized based on in-hospital opioid use are not universally adopted. 14 Non-stepwise protocols have resulted in patients receiving opioids without having the opportunity to have their pain managed with non-opioid analgesics. It has become more and more apparent that some women may not even need any systemic opioids post partum, 15 or that split doses will reduce overall opioid consumption. 16 Furthermore, two recent studies report a decreased in-hospital opioid use after the implementation of multimodal stepwise analgesic prescriptions for postpartum pain but did not include a control group and did not examine discharge prescription. 17 18 We conducted this study to test the hypotheses that a stepwise multimodal opioid-sparing anal- gesic computerized order set coupled with provider Protected by copyright. on March 2, 2021 at Columbia University Libraries. http://rapm.bmj.com/ Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102007 on 10 November 2020. Downloaded from