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Pain After C-Section: Are Opioids Really Necessary?

LAS VEGAS — Women who received non-opioid analgesia following cesarean delivery had a lower mean pain score than women who received opioids along with other pain medicine, a researcher said here.

A small randomized trial found mean pain scores lower for women in the non-opioid group versus the opioid group at 2-4 weeks postpartum, meaning opioids for pain may be inferior (12.3 vs 15.9, respectively, adjusted mean difference 4.8, 95% CI -2.1 to 11.9), reported Jenifer Dinis, MD, of McGovern Medical School at the University of Texas, Health Science Center in Houston.

In a presentation at the Society for Maternal-Fetal Medicine annual meeting, Dinis detailed how the “common practice” of prescribing 30 tablets for opioid analgesia for women who have had a C-section delivery could be contributing to the opioid crisis. For the 1.2 million C-section deliveries in the U.S., that accounts for 36 million tablets, she said, and if each patient has 10 tablets left over, that’s 12 million tablets “available for misuse.”

Given this growing crisis, Dinis and colleagues set out to examine if patients with C-section deliveries who were not given opioids for pain would have a similar pain score 2-4 weeks after delivery as patients who were given opioids.

They conducted a randomized, parallel-group equivalence trial of patients at Children’s Memorial Hermann Hospital and UT Health outpatient clinics in Houston. Participants were women, ages 18-50, with C-section deliveries who spoke English or Spanish and consented to the trial. They received an inpatient analgesia regimen at the recommendation of their primary ob/gyn, with the prescription for intervention placed in their chart and at 2-4 weeks, they were followed up in person, via phone and then emailed a link to record their pain score.

Patients randomized to the non-opioid arm received a prescription for 60 tablets, 600 mg each, of ibuprofen and 60 tablets, 325 mg each, of acetaminophen. The opioid group received the same ibuprofen prescription, but only 15 tablets of acetaminophen/hydrocodone (325 mg/5mg). Rescue hydrocodone was available to women after evaluation by a clinician if their pain was uncontrolled by their treatment regimen, although Dinis noted that 48% of women did not require opioids for pain control.

Pain score was measured by a visual analog scale, and the staff collecting the pain score was not aware of the allocated intervention, Dinis said.

Of the 170 patients who were randomized, data was available for 73 patients in the non-opioid group and 75 patients in the opioid group. Baseline characteristics were similar, with women a mean age of about 28. Notably, there was no difference in the type of C-section delivery between groups, Dinis commented.

Both groups then received a patient satisfaction survey on a 5-point Likert scale, and satisfaction with outpatient analgesics did not differ between groups.

Angela Bianco, MD, of the Icahn School of Medicine at Mount Sinai in New York City, commented that if clinicians were able to cut down on the number of opioids prescribed, it not only reduced the chance that these medications will be “redistributed into the general population,” but also could help avoid the potential for addiction in patients.

“This may change practice habits because we could opt not to prescribe narcotics post-discharge, or if we do, we could give patients fewer tablets,” Bianco, who was not involved with the research, told MedPage Today.

Dinis’ group also examined side effects and found no differences except that a significantly higher portion of patients in the opioid group reported somnolence, which Dinis described as “an unexpected finding.”

One limitation to the data was that patients were aware of their allocated intervention, which could have introduced bias.

Dinis and co-authors disclosed no relevant relationships with industry.