After C-Section, Non-Opioids Can Reduce Both Pain and Opioid Use

Ashraf Habib, MD

Nearly every demographic in the nation has been impacted by the opioid epidemic. According to the Centers for Disease Control and Prevention (CDC), the number of overdose deaths involving opioids is 6 times higher than it was in 1999 with an average of 130 people dying from an opioid overdose each day.¹ Further, studies show that women are 40% more likely than men to become newly persistent users of opioids following surgery², putting them at a greater risk of addiction and dependence. To assist this vulnerable population, it’s imperative to examine the effectiveness of non-opioid options that reduce the need for opioids after surgery.

While the risks and side effects of opioids are widely known, they continue to be used for pain management following many procedures, including Cesarean section (C-section). Women are keenly aware of these risks as research shows that 9 in 10 mothers have concerns about taking opioids after childbirth—yet 51% of C-section patients are still prescribed an opioid to manage pain.³

However, despite the use of multimodal analgesic regimens, a significant number of women still experience pain necessitating the use of rescue opioid analgesics following cesarean delivery. Therefore, there is a clear need for additional non-opioid strategies to reduce the need for rescue opioids with their associated risks and side effects.

In order to achieve this, I recently led a multicenter study to collect clinical evidence that a multimodal postsurgical pain regimen using a TAP block with EXPAREL (bupivacaine liposome injectable suspension) together with regular acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) could reduce opioid consumption more so than a standard multimodal pain control approach that combines TAP block with standard bupivacaine, regular acetaminophen, and NSAIDs. The study shows that patients receiving an EXPAREL TAP block experienced a statistically-significant reduction in total postsurgical opioid consumption, as well as significant reduction in pain intensity scores through 72 hours. Further, it achieved a statistically significant reduction in total opioid consumption at 1- and 2-weeks following C-section.

As physicians we must be more vigilant in reviewing pain management protocols for women undergoing C-section procedures, as research shows that inadequately managed postsurgical pain can interfere with a new mother’s ability to care for herself and her infant.⁴ Further, mothers experiencing severe pain following C-section procedures are at increased risk for persistent pain, persistent opioid use, and postpartum depression.^5,6

Separate research⁷ conducted by B. Wycke Baker, MD, Chief of Service, Anesthesiology at Texas Children's Pavilion for Women, Clinical Professor of Anesthesiology, Obstetrics and Gynecology at Baylor College of Medicine also studied the use of EXPAREL among C-section patients and was published in The Journal of Pain Research. This research found that women who underwent C-section procedures and received EXPAREL reported a decrease in postsurgical opioid consumption by 47%, a decrease in postsurgical pain intensity scores by 46%, and a reduced length of stay. Notably, a greater percentage of patients in this study treated with EXPAREL consumed no opioids after surgery compared to those treated without EXPAREL.

These studies provide encouraging results indicating that multimodal pain management protocols for women undergoing C-sections, that include a non-opioid option such as EXPAREL, can help improve pain management and reduce the need for opioids compared to current standard of care. The fight against the opioid epidemic requires a focused effort on all fronts nationwide. Utilization of opioid alternatives in women undergoing surgery can provide better patient outcomes without compromising care and will ultimately make way for a new wave of postsurgical options that can significantly limit opioid use.

Ashraf Habib, MD, is Chief of the Division of Women’s Anesthesia and Professor of Anesthesiology at Duke University and investigator in the study. The piece reflects the author's views, not necessarily those of the publication.

¹ https://www.cdc.gov/drugoverdose/epidemic/index.html

² Pacira. United States for Non-Dependence: An Analysis of the Impact of Opioid Overprescribing in America. September 2017. [Analysis in the report was based on research conducted by the QuintilesIMS Institute.]

³ Moms Meet Member Survey of 1,452 members. Responses collected from 3/16/2018 to 3/30/2018.

⁴ Karlström A, Engström-Olofsson R, Norbergh KG, Sjöling M, Hildingsson I. Postoperative pain after cesarean birth affects breastfeeding and infant care. J Obstet Gynecol Neonatal Nurs. 2007.

⁵ Lavand’homme P. Long-Term Problems and Chronic Pain After Caesarean Section. In: Capogna G. (eds) Anesthesia for Cesarean Section. Springer, Cham. May 6, 2017.

⁶ Kainu JP, Sarvela J, Tiippana E, Halmesmäki E, Korttila KT. Persistent pain after caesarean section and vaginal birth: a cohort study. Int J Obstet Anesth. 2010.

⁷ Pacira. New Retrospective Analysis Demonstrates Significant Reductions in Postsurgical Pain and Opioid Requirements with EXPAREL in Cesarean Section Patients. December 12, 2018.

Health care professionals and researchers interested in responding to this piece or similarly contributing to MD Magazine® can reach the editorial staff by submitting a request here.