Opioids: How to Reduce Use

A new post-surgery practice means many mothers don’t need opioids after c-sections.

When Karen Hanlon, 38, of Caldwell, gave birth to her first son, Henry, now almost 3 years old, opioids were a common form of pain relief at hospitals across the country.

Karen had a cesarean section (C-section), which requires an incision in the muscle of the belly and days of recovery. She says her pain while recovering, on a scale from one to 10, was always at level six or higher.

Once at home, she recalls, she remained sluggish, winded and groggy due to side effects of opioids she was taking to control the pain. It took her almost two weeks to be able to climb the stairs to her bedroom comfortably.

This past summer, she had a very different birth experience. She and her husband, Andrew, welcomed their second child, Charlie, and he was also born via C-section.

But this time, Karen had the benefit of a new way of controlling pain that didn’t involve opioids. Known as “enhanced recovery after surgery,” or ERAS, it is part of a broad effort by Saint Barnabas Medical Center (SBMC) to reduce opioid use in the hospital. The postoperative practice was first used in other areas of abdominal surgery and was introduced for C-section patients in January of 2019.

“ERAS has been wonderful for our other patients who had abdominal surgery, so we knew it would give tremendous benefits to our maternal patients, too,” says Paul Yodice, MD, Chairman of Medicine at SBMC. “It lets them avoid the side effects and risks of opioids. Plus, they are out of the hospital and home more quickly, celebrating the new baby with family and friends.”

“Given my experience with the first C-section, I never thought it could work without opioids,” Karen says. “But I was greatly surprised and definitely happy when it did.” With this second birth, Karen’s pain never went near a six on the pain chart, and it even stayed below level four, she says, still amazed. She was up and out of the hospital bed the first day after delivery and found she could visit with friends and family with more ease.

“I was able to focus more on Charlie, and less on the pain,” she says.

At the launch of SBMC’s Clinical Excellence and Effectiveness program, from left to right: Caitlin Tauro, Coordinator, CEE; Luciana Mullman, Administrative Director, CEE; Nnamdi Gwacham, MD, OB-GYN Resident; Richard Pitera, Jr., MD, Medical Director of Perioperative Medicine; Paul Yodice, MD, Chairman, Department of Medicine and Medical Director, CEE; Stephen Crane, MD, OB-GYN; Sheila A. Collier, MSN, RNC-MNN, Director, Maternal Child Services; and Stephen P. Zieniewicz, FACHE, President and CEO.


How ERAS Works

The ERAS effort is part of the comprehensive Clinical Excellence and Effectiveness (CEE) program put in place by SBMC in 2017. “Our mission is to reduce unnecessary variation to improve effectiveness of care with a multi-disciplinary approach between medical, nursing and ancillary services,” says Luciana Mullman, MPH, CSSGB, Administrative Director of the program. “The ERAS C-section program fits into this because we have standardized delivery of care into one evidence-based approach, which the team now follows.”

Efforts like ERAS are taking hold across the country as an important step in stemming the opioid epidemic, which the federal government declared a public health crisis in 2017. Last year, more than 10 million people misused opioids, according to U.S. government statistics, and on average, 130 people die each day from overdosing on opioids. Many people who are addicted to opioids first take them using a prescription they receive after surgery or an injury.

Hundreds of other mothers at SBMC have now had ERAS experiences similar to Karen’s. In the first six months of the program that staff call “amazing,” pain control was so effective that 70 percent fewer women needed or asked for opioids after delivering their babies via C-section. Even among the women who did need opioids during their stay, there was a 90 percent reduction in the number of doses needed overall.

Many specialists worked together to develop SBMC’s process for providing an alternative for pain control. “We’ve used tried-and-true steps for our patients after C-section, and added some innovative components,” says Richard Miller, MD, specialist in maternal-fetal medicine (care of the mother and unborn child) and Chair of the Department of Obstetrics and Gynecology at SBMC.

“We identified a procedure, known as TAP [transversus abdominis plane] block, where we can inject local anesthetics into the abdominal wall during surgery as a first step in controlling pain in that area,” says Richard Pitera, Jr., MD, Associate Chair of Anesthesiology. “This by itself can decrease pain up to 70 percent.”

After surgery, recovery room staff remove the catheter (used to help drain urine), instead of leaving it in for a day or two, as before. In addition to reducing the risk of infection, this makes the patient more comfortable and mobile.

The patient is out of bed within six hours post-surgery, and walks three times around the nursing unit daily.

Familiar medicines like Motrin and Tylenol are used to keep patients comfortable all day, versus use of strong opioids taken at longer intervals. These medicines also do not cause the grogginess that opioids do, and they are not addictive.

“The real secret to successful pain control is bringing in all the people involved with patient care—nurses, resident physicians, OR technicians and everyone along the way,” says Dr. Pitera. “Having a multidisciplinary team is what makes the difference.”

“Altogether, these steps allow our new mothers to get back to normal more quickly, and our patients’ satisfaction with their overall hospital experience has soared since January,” Dr. Miller says.

Long-Term Goals

The benefits of fewer opioid prescriptions continue after the patient leaves the hospital. Studies show that only half of opioids prescribed after C-section are ever needed at home, meaning dozens of pills remain in home medicine cabinets.

“With our program, fewer prescriptions means fewer opioids go home, in the reach of the patient, families and friends,” Dr. Yodice says. “Other lives may never be touched by opioids. And maybe we’ll have fewer patients with addiction coming to us in the Emergency Department and intensive care.

“It can happen, with efforts like this,” he says. “Hopefully, we are witnessing the beginning of the end of the opioid crisis.”

To find an obstetrician at Saint Barnabas Medical Center, call 888.724.7123.