Efficacy of a Pharmacist-led Educational

Intervention for Postpartum Pain Management

in Women with Opioid Use Disorder
Maggie Kline, PharmD
PGY1 Pharmacy Resident, IU Health Bloomington Hospital
Mentors: Alma Zajmi, PharmD, Sandy Siefers, PharmD, BCPS

The speaker has no actual or

potential conflict of interest in
relation to this presentation.
 IU Health Bloomington Hospital

297 beds
17 Labor and Delivery beds
24 Postpartum beds
Level 3 NICU
Bloomington has 2 local
women’s health provider groups
and 1 independent OB-GYN (18
maternity providers)
1 has X-waiver
2
 Pregnancy in Opioid Use Disorder (OUD)
 Medication-assisted therapy (MAT) improves maternal outcomes with low fetal
risk
⎻ Methadone
⎻ Buprenorphine +/- naloxone
⎻ Naltrexone – not recommended

 Stigma and perceived maternal-fetal conflict

 MAT improves birth weight and retention of maternal guardianship compared to
substitution treatment alone.

HHS Publication No. (SMA) 18-5054.

Addiction. 2012;107 Suppl 1(0 1):5-27.
3
Am J Obstet Gynecol. 2017;217(4):459.e1-459.e6.
J Addict Med. 2012;6(2):124-130.
 Pain Management in OUD

Increased opioid Use of opioid

Hyperalgesia
tolerance agonists for MAT

Relapse triggers:
pain, opioid Stigma
agonist exposure

4
Ann Intern Med. 2006 Mar 21;144(6):460.
Am J Addict. 2013 Jan;22(1):75-83.
 Postpartum Considerations in OUD

Schiff et al. Obstet Gynecol. 2018.

•N=4,154 pregnant women with OUD in Massachusetts 2012-2014, vital

statistics
•Overdose risk decreased as pregnancy progressed but was highest 7-12
months after delivery

Meyer et al. Eur J Pain. 2010.

•N=63 buprenorphine-maintained women retrospectively matched with

controls
•Buprenorphine maintained women experienced more postpartum pain
and required 47% more opioids after delivery compared to controls

5
Obstet Gynecol. 2018 Aug;132(2):466-474.
Eur J Pain. 2010 Oct;14(9):939-43.
 ACOG, ASAM, and SAMHSA Postpartum Recommendations

Continue MAT after delivery for maintenance

•Methadone may require dose reduction
•Buprenorphine can usually be continued at same dose

Do not alter MAT dosing to provide pain management

Opioid-tolerant mothers need higher doses of NSAIDs, acetaminophen, and short-

acting opioids.
•Avoid opioids after vaginal delivery.

Never provide medications with opioid antagonist properties to women with OUD
J Addict Med. 2020;14(2S Suppl 1):1-91
HHS Publication No. (SMA) 18-5054.
6
Obstet Gynecol. 2017;130(2):e81-e94
Obstet Gynecol. 2018;132(1):e35-e43
 Additional Postpartum Recommendations

Encourage breastfeeding if no contraindications.

Discharge Prescriptions:
Bateman et al. (2017): Opioids may be overprescribed at discharge
after C-section without increase in patient satisfaction in general
population.
If opioids are prescribed at discharge, consider a 3 day supply or 20
tablets. If greater need is expected, no more than a 7 day supply
should be provided at discharge.

Obstet Gynecol. 2017;130(2):e81-e94

7
Obstet Gynecol. 2017;130(1):29-35.
HHS Publication No. (SMA) 18-5054.
 Obstetrics Provider Practice Patterns

Study ●2017 Cross-sectional survey of ACOG members

●Response rate 34% (N=462)

●Mean of 20 years practice experience
●Most (72%) had >25% Medicaid patients

Findings ●Overall 37% of respondents reported confidence in treating

pregnant women who use opioids
●One-third of respondents reported frequently advising MAT to
pregnant patients with OUD
●Sixty percent reported always referring postpartum patients to
treatment

8
J Perinatol. 2020;40(3):412-421.
Self-assessment Question #1
 What is the strategy recommended by the American College of Obstetricians and
Gynecologists for treatment of opioid use disorder in pregnant women?
 A. Abstinence from all opioids including medication-assisted treatment.
 B. Medication-assisted treatment with buprenorphine or methadone in
combination with behavioral therapy.
 C. Naltrexone long-acting injections.
 D. Buprenorphine mono-products but not buprenorphine/naloxone.

9
Efficacy of a Pharmacist-Led Educational Intervention for
Postpartum Pain Management in Opioid Use Disorder

10
Study Objective
Determine efficacy of a pharmacist-led educational
intervention regarding pain management best practices
in postpartum patients with OUD

Study Design
Single-center, retrospective, pre- and post- intervention
chart review

11
Population
Inclusion Criteria:
 Women who had a baby AND:
 Positive urine drug screen (UDS) OR
 Diagnosis of OUD (ICD-10 Code F11) OR
 MAT home medication
Cohorts:
 Pre-intervention: July to December 2019
 Post-intervention October 2020 to March 2021
Exclusion Criteria:
 Less than 16 years old at time of delivery
 Active cancer
 No evidence of opioid use disorder per chart
(if UDS positive)
 Positive UDS only for non-opioid substances
without other evidence of OUD

12
Primary Endpoint

• MAT postpartum continuation strategy

• Appropriate = Continue or split home dose
• Inappropriate = Increased or held home MAT

Secondary Endpoints

• Use of agents with mixed agonist/antagonist properties such as

nalbuphine or butorphanol
• Opioids prescribed at discharge
• Use of NSAIDs, acetaminophen, and short-acting opioids during
admission
• Referrals made at discharge

13
Statistical Tests

Estimated two patients per week, so six month periods samples ~48

Categorical outcomes: Fisher’s Exact Analysis

Continuous data
Parametric: Student’s t-test
Non-parametric: Mann Whitney U test as appropriate

14
Timeline

Data from post-

September 2020:
intervention period
Data from pre- Education sent to
(Oct 2020 to March
intervention period local providers
2021*) was
(July – Dec 2019) about preliminary
collected and
was collected. findings and
compared to pre-
recommendations.
intervention period.

*Preliminary data for October to December 2020 are presented here. 15

 Education Provided

Key points
Education about emphasized:
December 2020:
initial results and appropriate
Education was in-services
best practices postpartum MAT
provided by video provided to labor
was sent to all dosing, avoiding
chat to one local & delivery and
local providers nalbuphine, and
provider group postpartum
and inpatient prescribing less
and independent nursing
pharmacists by than 20 opioid
OB-GYN. departments over
email in tablets after
3 sessions.
September 2020. Caesarian
section.

December 2020: Met with representatives from OB-GYN, anesthesiology,

psychiatry, and nursing to discuss potential order set creation. 16
 Results
Pre-Intervention Preliminary Post-Intervention

60 Encounters 23 Encounters
extracted extracted

22 patients
excluded: 13 patients
excluded:
-5 for appropriate
opioid use only -6 for appropriate
opioid use only
-6 did not meet
inclusion criteria -5 UDS positive
-11 UDS positive other substance
other substance -2 Other

38 patients included 10 patients included

17
 Baseline Characteristics
Pre-Intervention Post-Intervention
(n=38) (n=10)
Average age, years (range) 27.1 (17-39) 30.6 (25-37)

Race, n (%)
White 37 (97) 10 (100)
Black 1 (3) 0 (0)
OUD Treatment Status, n (%)
Buprenorphine 10 2
Buprenorphine/naloxone 14 4
Methadone 3 1
In remission without MAT 6 2
Active OUD 4 1
Unavailable 1 -
Noted insufficient prenatal care, n (%) 11 (29) 1 (10)
Caesarian delivery, n (%) 16 (42) 5 (50)
18
 Primary Endpoint: Postpartum MAT Continuation Strategy
20
18
18
16
Number of Encounters

14 Preliminary
12
p=1 for
appropriateness
10 (1 new initiation
8 excluded)
6 5 5
4
4
2 1 1 1
0
0
Continued Dose Split Dose Increased Dose New Initiation

MAT Continuation Strategy

Pre-intervention Post-intervention 19
 Results – Inpatient Pain Management
Pre-Intervention Post-Intervention
(n=38) (n=10)
Nalbuphine or butorphanol ordered, n (%) 30 (79) 8 (80)
Nalbuphine or butorphanol administered, n (%) 2 (5) 1 (10)

Received opioids after vaginal delivery, n (%) 9 (41) 2 (40)

Cesarean delivery, received opioids, n (%) 13 (81) 5 (100)

Average oral morphine milligram equivalents (SD) 87 (101) 142 (58)
Use of a PCA, n (%) 2 (13) 0 (0)

20
 Results – Regional Analgesia for Caesarian Section
Transverse
All C-section Bupivicaine HCl
abdominal Longer-acting
patients except TAP blocks
plane (TAP) Liposomal
1 received a reduce opioid
blocks use bupivacaine*
spinal block, consumption
infiltration of an may decrease
epidural, or after C-section
anesthetic to opioid use after
combined in patients who
numb receipt of
spinal epidural do not receive
peripheral intrathecal
prior to C- intrathecal
nerves of the morphine.
section. morphine.
lower abdomen.

Pre-Intervention Post-Intervention
TAP block performed prior to surgery, n (%) 3 (19) 4 (80)

*Liposomal bupivacaine became restricted to

Anesth Analg. 2020;131(6):1830-1839. neurosurgery at IU Health in December 2020. 21
Can J Anaesth. 2012;59(8):766-778.
 Results – Discharge Pain Management
Pre-Intervention Post-Intervention
(n=38) (n=10)
NSAID recommended at discharge, n (%) 32 (84) 10 (100)
Acetaminophen recommended at discharge, n (%) 15 (39) 5 (50)
Opioids prescribed at discharge, n (%) 8 (21) 5 (50)

Average quantity tablets 18.5 14.8

Average morphine milligram equivalents (MME) 100 83

22
Linkages to Treatment at Discharge
 For patients not previously receiving treatment:
 Pre-intervention:
⎻ 1 received facilitated referral to intensive inpatient treatment
⎻ 1 left AMA
⎻ 1 had no intervention noted
⎻ 1 received list of treatment providers
 Post-intervention: 1 initiated buprenorphine inpatient and received facilitated
referral to inpatient treatment

23
Discussion
 Preliminary results not statistically significant but showed some trends towards
increased provider awareness
 Initiation of buprenorphine prior to discharge
 Increased use of TAP block for pts undergoing C-section
 Preliminary results underpowered to detect a difference between groups
 Covid-19
 Intervention intensity and duration

24
Study Limitations

Retrospective chart
Hesitance to change review and
practice & “buy-in” deficiencies in
documentation

Subjective nature of Drug shortage

pain management patterns

25
Conclusion and Future Directions
 No difference was found in this study, likely due to the limited intensity of
intervention and small sample size.

 Further multidisciplinary collaboration with psychiatry, anesthesiology, and

obstetrics providers is needed.

 Increased access to buprenorphine initiation protocols in women’s health, the

emergency department, and other departments may further increase initiation of
and retention in treatment locally.

26
Self-Assessment Question #2
 How should postpartum pain be managed in a woman using maintenance-
assisted treatment (MAT) for opioid use disorder?
 A. Maintain home MAT dose and use standard doses of pain medications.
 B. Maintain home MAT dose and use higher-than-standard doses of pain
medications.
 C. Hold home MAT and use standard doses of pain medications.
 D. Increase MAT dose to manage pain.

27
References
 Substance Abuse and Mental Health Services Administration. Clinical Guidance for Treating Pregnant and
Parenting Women With Opioid Use Disorder and Their Infants. HHS Publication No. (SMA) 18-5054.
Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018.
 Jones HE, Heil SH, Baewert A, et al. Buprenorphine treatment of opioid-dependent pregnant women: a
comprehensive review. Addiction. 2012;107 Suppl 1(0 1):5-27. doi:10.1111/j.1360-0443.2012.04035.x
 Caritis SN, Bastian JR, Zhang H, et al. An evidence-based recommendation to increase the dosing frequency
of buprenorphine during pregnancy. Am J Obstet Gynecol. 2017;217(4):459.e1-459.e6.
doi:10.1016/j.ajog.2017.06.029
 Meyer M, Benvenuto A, Howard D, et al. Development of a substance abuse program for opioid-dependent
nonurban pregnant women improves outcome. J Addict Med. 2012;6(2):124-130.
doi:10.1097/ADM.0b013e3182541933
 Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or
buprenorphine therapy. Ann Intern Med. 2006 Jan 17;144(2):127-34. Erratum in: Ann Intern Med. 2006 Mar
21;144(6):460.
 Eyler EC. Chronic and acute pain and pain management for patients in methadone maintenance treatment.
Am J Addict. 2013 Jan;22(1):75-83. 28
References Continued
 Schiff DM, Nielsen T, Terplan M, Hood M, Bernson D, Diop H, Bharel M, Wilens TE, LaRochelle M, Walley AY,
Land T. Fatal and Nonfatal Overdose Among Pregnant and Postpartum Women in Massachusetts. Obstet
Gynecol. 2018 Aug;132(2):466-474.
 Meyer M, Paranya G, Keefer Norris A, Howard D. Intrapartum and postpartum analgesia for women
maintained on buprenorphine during pregnancy. Eur J Pain. 2010 Oct;14(9):939-43.
 The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. J
Addict Med. 2020;14(2S Suppl 1):1-91.
 Committee on Obstetric Practice. Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in
Pregnancy. Obstet Gynecol. 2017;130(2):e81-e94.
 ACOG Committee Opinion No. 742: Postpartum Pain Management. Obstet Gynecol. 2018;132(1):e35-e43.
 Ko JY, Tong VT, Haight SC, Terplan M, Snead C, Schulkin J. Obstetrician-gynecologists' practice patterns
related to opioid use during pregnancy and postpartum-United States, 2017. J Perinatol. 2020;40(3):412-
421.

29
References Continued
 Nedeljkovic SS, Kett A, Vallejo MC, et al. Transversus Abdominis Plane Block With Liposomal Bupivacaine for
Pain After Cesarean Delivery in a Multicenter, Randomized, Double-Blind, Controlled Trial. Anesth Analg.
2020;131(6):1830-1839. doi:10.1213/ANE.0000000000005075
 Mishriky BM, George RB, Habib AS. Transversus abdominis plane block for analgesia after Cesarean delivery:
a systematic review and meta-analysis. Can J Anaesth. 2012;59(8):766-778. doi:10.1007/s12630-012-
9729-1

30
Efficacy of a Pharmacist-led Educational
Intervention for Postpartum Pain Management
in Women with Opioid Use Disorder
Maggie Kline, PharmD
PGY1 Pharmacy Resident, IU Health Bloomington Hospital
mkline4@iuhealth.org