Doctors at Dell Medical School at the University of Texas and at all Seton Healthcare Family hospitals are rethinking they way they treat mothers for pain after a Cesarean section or a vaginal delivery.
The new protocol has decreased the use of opioids by more than 40 percent while new moms are in the hospital. “We changed the way we want to manage pain,” says Dr. Amy Young, chair of the Department of Women’s Health at Dell Medical School and head of Women’s Health at Seton.
Beginning in February 2017, Seton and Dell Medical School changed the questions doctors and nurses asked about pain level, the way they measured that pain level and the way they gave out pain medication.
The hope was that they could lessen the amount of opioid medications given after birth to then lessen the possibility of addiction later.
In 2012-2015 in Texas, drug overdose was the No. 1 cause of accidental death in women within a year of giving birth, according to state Department of Health Services. That same study found that more than half of those overdoses involved an opioid.
Now instead of asking moms to rate their pain on a scale of 1 to 10 or to look at a series of smiley and not-so-smiley faces, doctors and nurses are asking moms how they are doing with functional activities such as the ability to get up and go to the bathroom and the ability to sleep comfortably.
The previous pain scales were subjective, Young says. “I’m a big gigantic ninny when it comes to pain,” she says. “I’m terrible at it. My 1 might be your 10.”
Using the number scale might mean that a mom might say she was a 3 and be given one pain regimen, but really her pain was the same as another mom’s 7, who got a different pain regimen.
Now doctors and nurses are automatically giving moms a combination of acetaminophen (Tylenol) and ibuprofen (Advil) every six hours, unless they are allergic or don’t want it. Those two drugs work differently when it comes to how they control pain. Nurses also aren’t waiting for a woman to be in pain before giving her those medications.
What doctors and nurses found was that for many women, that was enough. They didn’t need the narcotics. For other women, who still reported pain when trying to do functional things, they were first given oral hydrocodone. If that still didn’t do it, they are given an intravenous pain medication like morphine.
Women who had had C-sections were more likely to need more than the acetaminophen/ibuprofen combination than those who had a vaginal birth.
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They also watched how patients rated their pain management in surveys. The hospital and school actually found those numbers either stayed the same as before they changed the protocol or improved slightly.
“This was a culture change,” Young says, “that took pretty embedded prescribing practices and changed them.” The fear was that patients would be in pain or that the acetaminophen/ibuprofen combination wouldn’t be enough, she says.
The change means that more moms aren’t leaving the hospital with the side effects of opioids such as constipation, feeling sedated and not being able to care for their babies because of that, or having withdrawal symptoms, she says.
“Any reduction that you can make (in opioid use in the hospital) should translate into a reduction in outpatient utilization,” Young says. “It’s a reduction of the number of narcotics floating around. It’s my little tiny place in the fight.”
A future study will look at opioid use after birth to compare what doctors are prescribing patients as they leave the hospital and what they actually fill and use.
Other hospital systems are looking at what Seton has done and some have even adopted Seton’s protocol, Young says. She plans to publish a paper on what they found in changing the pain protocol.
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