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Alternatives to Opioids (ALTO)- An Initiative to Reduce Opioid Use in Cesarean Section Patients
Abstract Number: F3A-395
Abstract Type: Original Research
Background-The opioid crisis in the US has had a devastating toll with >400,000 overdose deaths from 1999-2017. This epidemic has been driven by the misuse of prescription narcotics which then serves as a gateway to the use of heroin and illicit fentanyl. Cesarean section is the most common major surgical procedure in the US and opioids are routinely prescribed, both in the hospital and at discharge. Studies have reported an increased risk of new,persistent opioid use after prescription for acute pain in opioid naïve patients(1). Additionally, excessive prescribing leads to leftover medications which may then end up in the possession of an abuser. We recently introduced an initiative - the Alternatives to Opioids (ALTO) program- with the aim of decreasing opioid use following cesarean delivery, and we report our first year’s results.
Methods- A multidisciplinary team was created including OB/Gyn and anesthesia faculty and residents,nursing, pharmacy and the director of the ALTO program(a pain fellowship-trained ER physician). Guidelines for post-section pain management were established. Initial management was with intrathecal or epidural morphine. Orders then included 4 doses of ketorolac,30 mg IV q 6 hrs;acetaminophen,975 mg po q 6 hrs x 72 hrs; and ibuprofen, 400mg po q 6hrs x 48 hrs following the ketorolac. Oxycodone/acetaminophen was removed from the order sets and replaced with oxycodone 5mg po q 6hr prn for rescue. Patients were discharged on ibuprofen and acetaminophen and pharmacy developed a hand out on the proper use of these drugs in combination. A small number of oxycodone tabs could be prescribed as needed.
Results: Prior to the start of the program 85% of patients used opioids post-section. This dropped to between 36-45% each quarter of 2018 as most pain needs were satisfactorily addressed by non-opioid analgesics. Initially 88.5% of patients were discharged with a prescription for narcotics but at the end of 2018 only 4% of patients received such a prescription.Discussion:In the US,but not Europe, opioids for post-cesarean section pain are prescribed both in the hospital and upon discharge. This difference in practice may relate to the push in the US for treating pain as a “5th vital sign” with a tie in to reimbursement; and misguided teaching that narcotics were not addictive when given in the setting of pain. These factors have also contributed to the opioid epidemic(2). The use of multi-modal analgesia without opioids has been shown to be non-inferior to opioid regimens for moderate to severe pain(3).We developed institutional guidelines that maximized around-the-clock non-opioid analgesic use and were thereby able to minimize in-house and discharge opioid use.
Conclusion: By focusing on provider and patient education in multi-modal pain relief, in-hospital opioid use was halved and discharge prescriptions virtually eliminated.
1 Sun,JAMA Intern Med;176,2016
2.Wong, BJA, 121(2) 2018
3.Chang,JAMA Intern Med 318(17) 2017