Are Opioids Really Necessary After a C-Section?
One doctor thinks overprescribing pain meds post-delivery is a contributing factor to the current opioid crisis.
The world of labor and delivery is changing, fast. Not only have scientists found a way to speed up labor, but women are also opting for gentler C-section methods. While C-sections still aren't recommended by the World Health Organization unless deemed medically necessary, sometimes they are necessary. And the latest scientific breakthrough may make the recovery process faster, less painful, and less addicting.
Of course, C-sections themselves aren't addicting, but the drugs often used in the recovery process-opioids like Percocet or Vicodin-are. And a new report from the QuintilesIMS Institute found that 9 in 10 surgery patients receive opioid RXs to manage postsurgical pain. They're given an average of 85 pills each-a number that may be too high, as the report also found that overprescribing opioids after surgery resulted in 3.3 billion unused pills in 2016 alone.
A new study published in Obstetrics & Gynecology backs that up for women recovering from C-sections. After analyzing 179 patients, they found that while 83 percent used opioids for an average of eight days after discharge, 75 percent still had unused pills. That's particularly dangerous for women, as the QuintilesIMS report found females were 40 percent more likely to become persistent opioid users after exposure.
So, if women are more likely to become addicted to opioids, one question arises: Is there a way to stop relying on them when recovering from a C-section? One doctor-Richard Chudacoff, M.D., an ob-gyn in Dumas, TX-thinks the answer is a resounding yes.
Dr. Chudacoff says he's been using alternate pain management protocols for the last several decades, as he's seen the downward spiral patients can find themselves in when taking opioids. "It's amazing the snowball effect they can have," he explains. "Opioids don't remove pain, they just make you not care that the pain is there, which means you don't care about just about everything else." But if you remove opioids from the equation, Dr. Chudacoff says patients feel more mental clarity after giving birth.
On top of that, Dr. Chudacoff estimates that the majority of those with an opioid or heroin addiction began with taking pain pills, likely after a surgery like a C-section, because it's often someone's first exposure to them. "You go home with this bottle of pills and it's easy to use them to help you sleep, move, and make you feel better if you're a little depressed." (Postpartum depression is more common than you think.)
Still, C-sections are a very major surgery and you're going to want pain relief should you need one. (Read more at Parents.com: Experts Weigh the Pros and Cons of Taking Opioids After a C-Section) And to be fair, plenty of women take painkillers for short-term relief without an issue. Chronic use is where you start getting into problems-but these problems are major. The Centers for Disease Control and Prevention (CDC) found that fatal overdoses from prescription opioids have quadrupled since 1999, accounting for an estimated 15,000 deaths in 2015.
The key is reviewing your options with your doctor in advance. As an alternative, Dr. Chudacoff has been using Exparel, a non-opioid injection that's administered during surgery and slowly relieves pain over 72 hours. He learned about the anesthetic when his close friend, the executive director of a surgery center, told him about it being used by colorectal surgeons who were dealing with hemorrhoid patients, along with doctors performing knee surgeries. The patients were reporting a lack of pain for upwards of four days, so Dr. Chudacoff did additional research to see if it could work in C-sections and hysterectomies.
Eventually, he performed his first opioid-free C-section and says the patient never required a postsurgical prescription. Same goes for each one he's performed since. "I haven't written prescriptions for postoperative opioids in three months," he notes, explaining that his standard of care instead alternates between acetaminophen (Tylenol) or ibuprofen (Motrin) to "pre-treat pain in a non-opioid fashion; eliminating the risk for addiction."
On top of that, Dr. Chudacoff says his Exparel patients are, on average, out of bed and walking within three hours of surgery, and "99 percent have walked, peed, and eaten within six hours. Our average hospital stay is down to 1.2 days." The American Congress of Obstetricians and Gynecologists (ACOG) says the average hospital stay for a C-section is two to four days, so that's a significant difference.
While this sounds like the answer to every laboring woman's painful prayer, the drug doesn't come without caveats. First, it's expensive. Dr. Chudacoff says that the hospital he currently works at covers the cost of the drug for patients, but that's not standard protocol, and the wholesale price for a 20-mL vial of Exparel is about $285. "This is so recent of a medication, at least for C-sections, that the majority of ob-gyns aren't even aware of it," he says. It's also not covered by insurance, he adds, which is why he recommends checking with your local hospital about additional medical costs that you'd be responsible for before signing on the dotted line.
Price isn't the only concern, though. Two studies found the drug wasn't any more effective in relieving knee surgery pain than bupivacaine, an injectable spinal anesthetic that's been the standard of care for various surgeries, including C-sections. But that doesn't mean it isn't effective in reducing opioid use. When researchers administered Exparel to knee surgery patients-instead of the standard bupivacaine-total opioid consumption decreased by 78 percent in the first 72 hours after surgery, with 10 percent remaining opioid-free, according to a study published Journal of Arthroplasty. That makes sense considering that Exparel lasts approximately 60 hours longer.
"This really is the start of a big potential breakthrough," he says. "If you consider that C-sections are one of the most common procedures in the United States, at 1.2 million a year, that means you could drop the number of opioid prescriptions by over a million each year, which would be huge for combating the epidemic we're currently in."