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A shared decision-making intervention for opioid prescribing after cesarean delivery: a single-arm trial
Abstract Number: GM-06
Abstract Type: Original Research
Background: There is a need to define strategies that align the amount of prescription opioids dispensed with what patients will require and thereby reduce the number of leftover prescription opioid tablets available for diversion or misuse. The aim of this study was to assess the impact of a shared decision-making model to guide opioid prescribing practices after cesarean delivery (CD).
Methods: Following IRB approval, 50 patients consented to participate in this single-arm trial in which patients self-selected the number of tablets of oxycodone prescribed following CD. An interactive, iPad-based decision aid formed the basis of the shared decision-making session, which occurred on the day prior to discharge. Through this decision aid, patients were presented information on typical trajectories of pain resolution and normative opioid consumption following CD, risks, benefits, and alternatives to opioids, and instructions on safe disposal of unused opioids. At the end of the session, patients chose the number of oxycodone 5mg tablets to be prescribed upon discharge, up to a total of 40 tablets. Telephone follow-up was performed 2 weeks after discharge. Summary statistics were used to describe study participants and a one-sided, one-sample t-test was performed to compare the mean number of oxycodone tablets chosen to the institutional standard of 40 tablets. The sample size of 50 women was based on 90% power to show a reduction in the mean oxycodone prescription from 40 to 35, assuming a standard deviation (SD) of 12 and alpha=0.05. Data were analyzed with Stata 14 (College Station, TX).
Results: The mean (SD) number of oxycodone 5mg tablets chosen by the patients was 20.6 (10.6), which was significantly less than the historically prescribed standard of 40 tablets (p<0.001) (Table). The mean (SD) number of leftover tablets was 6.4 (7.7). Among the 32 patients with unused oxycodone tablets who did not receive refills, 66% had a safe plan for disposal. At 2-week follow-up, 90% of patients reported being satisfied or very satisfied with their outpatient pain control. 4 patients (8%) required medication refills; 3 of these patients had infectious complications leading to greater than usual postoperative pain. No differences were seen in the amount of oxycodone chosen or used based on type (primary vs. repeat) or timing (scheduled vs. unscheduled) of CD.
Conclusions: The shared decision-making approach to opioid prescribing following CD reduced the number of opioids prescribed after CD at our institution by approximately half, while maintaining very high levels of patient satisfaction with the treatment of their pain. This novel approach is a promising strategy to reduce the amount of leftover opioid medication following CD, the most commonly performed surgical operation in the US.