Vanderbilt University School of Medicine, Nashville, TN.
Division of Obstetric Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
Am J Obstet Gynecol MFM. 2021 Jan;3(1):100286. doi: 10.1016/j.ajogmf.2020.100286. Epub 2020 Dec 3.
Strategies to curb overprescribing have focused primarily on the prescriber as the point of intervention. Less is known about how to empower patients to use fewer opioids and decrease the quantity of leftover opioids. Previous studies in nonobstetrical populations suggest that patient counseling about appropriate opioid use improves disposal of unused opioids and overall knowledge about opioid use. Less is known about whether counseling reduces opioid use after hospital discharge.
This study examines whether enhanced discharge counseling on optimal analgesic use after cesarean delivery reduces opioid use and improves proper disposal of unused opioids and opioid use knowledge after hospital discharge.
Women who underwent an uncomplicated cesarean delivery were randomized to enhanced counseling on optimal analgesic use or usual care. Enhanced counseling addressed the following 4 points: (1) pain is normal after cesarean delivery; (2) scheduled ibuprofen should be taken to maintain baseline pain control; (3) opioids should be used sparingly and should be tapered over several days; and (4) all unused opioids should be returned to pharmacy or flushed in a toilet. All participants received 30 tablets of 5 mg hydrocodone-acetaminophen and 30 tablets of 600 mg ibuprofen at discharge. They were contacted 14 days later to determine opioid use and location of leftover opioids and to complete a 10-question analgesic strategies quiz with a score of 1 to 10. We estimated that outcome data on 172 women total would provide an 80% power to detect a 30% reduction in postdischarge opioid use with enhanced counseling.
Notably, 79% of eligible women consented to the study and 175 of 196 participants (84 enhanced counseling, 91 usual care) completed the follow-up. Compared with usual care, the enhanced counseling group was more likely to follow recommendations for proper opioid disposal (risk ratio, 2.3; 95% confidence interval, 1.3-3.9). They also scored significantly higher on the analgesic strategies quiz (10 points [interquartile range, 9-10] vs 8 points [interquartile range, 7-9]; P<.001) than the usual care group. Although the enhanced counseling group used less opioids (7.5 tablets [interquartile range, 2-15] vs 10.0 tablets [interquartile range, 2-16]; P=.55) and a smaller proportion of prescribed opioids (25.0% [6.7-50.0] vs 33.3% [6.7-53.3], P=.55) than the usual care group, differences were not statistically significant. There was no statistically significant evidence of interaction between participant education level and any of the study outcomes.
Enhanced discharge opioid counseling doubled the frequency of participants reporting proper opioid disposal and improved overall knowledge about the risks associated with opioids. This intervention did not decrease opioid use in a population of women with low overall opioid use. These findings highlight possible methods to intervene on the short-term (misuse and diversion) and long-term (persistent opioid use) consequences of overprescribing.
抑制过度处方的策略主要集中在干预开方者。关于如何赋予患者使用更少的阿片类药物并减少剩余阿片类药物数量的知识知之甚少。非产科人群的先前研究表明，关于适当使用阿片类药物的患者咨询可改善未使用的阿片类药物的处理和整体阿片类药物使用知识。关于咨询是否可以减少出院后的阿片类药物使用，知之甚少。
本研究检查了增强剖宫产术后最佳镇痛使用的出院咨询是否可以减少阿片类药物的使用，并改善出院后剩余阿片类药物的正确处理和阿片类药物使用知识。
接受简单剖宫产的女性被随机分配接受增强的最佳镇痛使用咨询或常规护理。增强咨询涉及以下 4 点：（1）剖宫产术后疼痛是正常的；（2）应服用计划中的布洛芬以维持基线疼痛控制；（3）应谨慎使用阿片类药物，并在几天内逐渐减少；（4）所有未使用的阿片类药物应退还给药房或在马桶中冲洗。所有参与者在出院时都收到了 30 片 5 毫克氢可酮-对乙酰氨基酚和 30 片 600 毫克布洛芬。14 天后联系他们以确定阿片类药物的使用情况以及剩余阿片类药物的位置，并完成 10 个问题的镇痛策略测验，分数为 1 到 10。我们估计，总共需要 172 名女性的结局数据，才能有 80%的效力来检测增强咨询后阿片类药物使用减少 30%。
值得注意的是，有 79%符合条件的女性同意参加该研究，有 175 名参与者（增强咨询组 91 名，常规护理组 84 名）完成了随访。与常规护理相比，增强咨询组更有可能遵循适当的阿片类药物处理建议（风险比，2.3；95%置信区间，1.3-3.9）。他们在镇痛策略测验中的得分也明显更高（10 分[四分位数范围，9-10]比 8 分[四分位数范围，7-9]；P<.001）比常规护理组。尽管增强咨询组使用的阿片类药物较少（7.5 片[四分位数范围，2-15]比 10.0 片[四分位数范围，2-16]；P=.55）和规定的阿片类药物比例较小（25.0%[6.7-50.0]比 33.3%[6.7-53.3]，P=.55）比常规护理组，但差异无统计学意义。在参与者教育水平和任何研究结果之间没有统计学意义的交互证据。
增强的出院阿片类药物咨询使报告适当阿片类药物处理的参与者的频率增加了一倍，并提高了对阿片类药物相关风险的整体认识。在阿片类药物总体使用量较低的女性人群中，这种干预措施并未减少阿片类药物的使用。这些发现突出了干预过度处方的短期（滥用和转移）和长期（持续使用阿片类药物）后果的可能方法。
