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Preliminary Evaluation of a Post-Cesarean Analgesic Protocol for Women on Buprenorphine Maintenance Therapy
Abstract Number: F5B-1
Abstract Type: Original Research
In conjunction with the psychiatrists who manage the antenatal opioid dependence (OD) clinic at our center, we developed a peripartum analgesic protocol for women on buprenorphine maintenance therapy. The protocol dictates a patient stop buprenorphine upon admission for cesarean delivery (CD), and a fentanyl patch is then applied. Intra-operative anesthesia is achieved with a CSE, followed by post-operative epidural analgesia with bupivacaine, fentanyl, and clonidine, combined with scheduled Tylenol and ibuprofen. A new fentanyl patch is placed prior to hospital discharge with a plan to restart buprenorphine at the first sign of withdrawal. No oral or intravenous opioids are administered at any time. We conducted a retrospective chart review to compare post-cesarean analgesia between women managed on protocol versus off protocol. Women on methadone and control patients (1:1 match) were identified for comparison.
Retrospective query of electronic records was used to identify records, and manual review was used to record variables of interest. Our primary outcome measure was the median pain score in the first 24 hours following CD for buprenorphine patients managed on protocol, compared to those patients not on protocol using a Mann-Whitney U test. Exploratory outcomes included postpartum length of stay (PPLOS), median pain score 24-48 hours post-CD, and total opioid consumption during the first and second 24 hours post-CD, calculated as milligram morphine equivalents (MME).
Electronic query identified 11 patients taking buprenorphine managed on protocol, 12 taking buprenorphine managed off protocol, 9 taking methadone, and 32 controls without OD. The buprenorphine protocol reduced median pain scores in the first 24 hours after CD (median [interquartile range] 5.0 [3.3,5.5] vs 7.0 [5.8,7.3], p=0.026) but were not different in the second 24 hours. Exploratory outcomes are presented in the table.
Our protocol demonstrated a significant reduction in reported median pain scores in the first 24 hours following CD. Further research is needed to determine the optimal protocol to care for patients on buprenorphine maintenance. In particular, long term follow-up is needed to determine whether our protocol of discharging patients with a fentanyl patch and no oral opioid tablets reduces risk of relapse for this population.