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Post-cesarean Pain in Parturients on Buprenorphine: A Single Center Retrospective Study
Abstract Number: F5B-2
Abstract Type: Original Research
Opioid use disorder in pregnancy is increasing. ACOG recommends opioid replacement therapy (ORT) for these patients during pregnancy1. Buprenorphine, a mu-opioid receptor partial agonist, is increasingly used for ORT. Patients on ORT have increased pain scores and opioid consumption compared to controls2. Poorly controlled postpartum pain may be a risk for adverse maternal and neonatal outcomes3. We sought to categorize post-operative pain in patients maintained on buprenorphine following cesarean delivery (CD) at our institution.
We performed a retrospective analysis of parturients maintained on buprenorphine (BUP) compared to matched opioid naive controls (non-BUP) 1:2. Primary outcome was post CD pain scores. Secondary outcomes include opiate consumption (IV morphine equivalents) and pharmacologic treatment of opioid side effects. Pain scores by postpartum day were analyzed by study group, with subgroup analysis based on buprenorphine dose. Analyses were compared using two sample t-tests. Demographics were compared by two-sample t-test for continuous variables and contingency tables with chi-squared test for categorical variables. P-value ≤0.05.
45 patients (14 BUP, 31 non-BUP) were analyzed. The primary outcome of total weighted average pain score was higher in the BUP group (BUP 5.61; non-BUP 3.16 (P<0.000001)). Mean high and low pain scores were also higher (BUP 7.9; non-BUP 6.19 (p<0.000001)) and (BUP 2.86; non-BUP 0.64 (p<0.000001)). Pharmacologic treatment of opioid-related side effects were similar between groups (BUP 14%; non-BUP 39% (P=0.2)). BUP parturients were more likely to receive a multimodal-postpartum analgesic regimen. Acetaminophen administration was 86% in BUP and 32% non-BUP (p0.003). NSAID administration was similar between groups (BUP 93%; non-BUP 97% (p0.99)). There was a >100% increase in opiate consumption in the BUP group compared to the non-BUP group, with patients on >16mg buprenorphine/24 hours reporting statistically significant higher pain scores.
Patients on buprenorphine have increased opiate requirements following CD, likely due to tolerance, hyperalgesia and decreased efficacy of supplemental opioids2. Despite >100% increase in post-CD opiate consumption and increased utilization of multimodal analgesia, our study revealed significantly increased pain scores in BUP compared to non-BUP. Other studies have demonstrated similar findings2. There is little evidence to suggest a correlation between high pain scores and functional recovery. The tolerable pain level may be much higher in women on buprenorphine ORT, which is not reflected in current treatment protocols. Additional studies are needed to further characterize post CD recovery outcomes to determine optimal analgesia protocols.
1) Comm Opinion 711. Obstet Gynecol 2017
2) Meyer M et al. Obstet Gynecol 2007
3) Leung AY. J Clin Anesth 2004