Why we are recommending this best practice
Strategies for implementation
- Consult with an anesthesiologist at the delivering facility who will be able to review and develop an anesthetic plan that addresses the patient’s needs and accounts for the options available at the local institution.
- Utilize shared decision making for the degree of pain relief desired during intrapartum and postpartum recovery.
- Provide resources for anesthesia providers about OUD and anesthetic consideration/needs.
- Neuraxial anesthesia provides the best quality of pain relief, especially in opioid tolerant individuals. Patients will need adjustment of medication types and concentrations for optimal pain relief that do not interfere with and will not be affected by OUD or OUD medications. Increased strength or concentration of a medication (e.g., local anesthetic or the total dose or frequency of a dose of a medication that has a uniform concentration) will likely be needed. Neuraxial adjuncts may be helpful. Patients with a prior history of OUD who fear relapse may desire a method of analgesia/anesthesia that omits opioids entirely.
- Avoid nitrous oxide in combination with high dose opioids. Nitrous oxide is not recommended in this setting as nitrous combined with opioids may produce excessive sedation or respiratory depression, causing the patient deep sedation or general anesthesia. When the preferred method, epidural analgesia, is contraindicated, nitrous oxide may be considered under close supervision as an adjunct with other systemic therapies.
- Adjust use of neuraxial anesthesia according to the individual patient’s OUD or OUD medications and tolerances. Adjunct neuraxial medications may be considered.
- Use general anesthesia only as otherwise indicated. This is not the preferred method for routine cesarean in pregnant women with OUD.
Post-delivery pain relief
- Create a multimodal analgesia and multidisciplinary care plan.
- Understand that multiple non-narcotic adjuncts are available. Choices may be affected by local resources and availability.
- Emphasize local anesthetics used in neuraxial infusion and/or peripheral nerve blocks (e.g, Transverse Abdominis Plan (TAP), Quadratus Lumborum Block (QL2), epidural infusion, and wound liposomal bupivacaine). Consider use of a catheter for continued infusion of local anesthetics and adjuvants, as well as scheduled acetaminophen and NSAIDs.
- IV patient-controlled analgesia (PCA) opioids may be used as a supplement to other multimodal treatment, but the requirements may be higher.
- Post-delivery monitoring requirements should be considered.
- Develop an informational packet for anesthesia providers.
- If the patient was previously on buprenorphine, continue buprenorphine, although the dose may need to be split (e.g.,TID), and total dose may need to be increased.
- Use of multiple opioids, analgesics, adjuncts, and/or sedatives may result in pharmacologic/pharmacogenetic additive or synergistic effects and result in shifting from minimal sedation to moderate sedation/analgesia to deep sedation/analgesia or even general anesthesia. Caution is urged, and proper monitoring for respiratory depression and oxygenation may be warranted. Underlying medical conditions will amplify the effect of sedatives, analgesics and other medications (e.g., obstructive sleep apnea, chorioamnionitis with fever). Rescue capacity is required under the Patients’ Rights standard at §482.13(c)(2), guaranteeing patients care in a safe setting (CMS Interpretive guidelines).
- Pan A, Zakowski M. Peripartum anesthetic management of the opioid- tolerant or buprenorphine/suboxone-dependent patient. Clin Obstet and Gynecol. 2017; 60(2): 447-458. doi:10.1097/grf.0000000000000288.
- Soens MA, He J, Bateman BT. Anesthesia considerations and post-operative pain management in pregnant women with chronic opioid use. Semin Perinatol. 2019; 43(3): 149-161. doi:10.1053/j.semperi.2019.01.004.
- George RB, Carvalho B, Butwick A, Flood P. Postoperative analgesia, chapter 29. In: Chestnut DH, Nathan N, eds. Chestnuts Obstetric Anesthesia: Principles and Practice. Philadelphia, PA: Elsevier; 2020.
- Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology. 2016;124(3):535-552. doi:10.1097/aln.0000000000000975.
- Hoyt MR, Shah U, Cooley J, Temple M. Use of epidural clonidine for the management of analgesia in the opioid addicted parturient on buprenorphine maintenance therapy: an observational study. Int J Obstet Anesth. 2018;34:67-72. doi: 10.1016/j.ijoa.2018.01.001.
- Landau R. Post-cesarean delivery pain. Management of the opioid- dependent patient before, during and after cesarean delivery. Int J Obstet Anesth. 2019;39:105-116. https://doi.org/10.1016/j.ijoa.2019.01.011.
- Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. American Society of Anesthesiologists. https://www.asahq.org/standards-and-guidelines/continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedationanalgesia#/. Accessed December 19, 2019.
- Volpe DA, McMahon Tobin GA, Mellon RD, Katki AG, Parker RJ, Colatsky T, et al. Uniform assessment and ranking of opioid mu receptor binding constants for selected opioid drugs. Regul Toxicol Pharmacol. 2011; 59:385- 90. doi: 10.1016/j.yrtph.2010.12.007.
- Enhanced Recovery After Cesarean (ERAC) Full Consensus Statement 5/23/2019. Society for Obstetric Anesthesia and Perinatology. https://soap.org/education/provider-education/member-erac-consensus- statement-5-23-19-2/. Published May 23, 2019.