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Effect of a stepwise opioid-sparing analgesic protocol on in-hospital oxycodone use and discharge prescription after cesarean delivery
  1. Ruth Landau1,
  2. Erik Romanelli2,
  3. Bahaa Daoud1,
  4. Ben Shatil3,
  5. Xiwen Zheng1,
  6. Beatrice Corradini1,
  7. Janice Aubey1,
  8. Caroline Wu1,
  9. Catherine Ha1 and
  10. Jean Guglielminotti1
  1. 1Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
  2. 2Anesthesiology, Montefiore Medical Center, Bronx, New York, USA
  3. 3Anesthesiology, Emory University, Atlanta, Georgia, USA
  1. Correspondence to Dr Jean Guglielminotti, Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA; jg3481{at}


Introduction Opioid exposure during hospitalization for cesarean delivery increases the risk of new persistent opioid use. We studied the effectiveness of stepwise multimodal opioid-sparing analgesia in reducing oxycodone use during cesarean delivery hospitalization and prescriptions at discharge.

Methods This retrospective cohort study analyzed electronic health records of consecutive cesarean delivery cases in four academic hospitals in a large metropolitan area, before and after implementation of a stepwise multimodal opioid-sparing analgesic computerized order set coupled with provider education. The primary outcome was the proportion of women not using any oxycodone during in-hospital stay (‘non-oxycodone user’). In-hospital secondary outcomes were: (1) total in-hospital oxycodone dose among users, and (2) time to first oxycodone pill. Discharge secondary outcomes were: (1) proportion of oxycodone-free discharge prescription, and (2) number of oxycodone pills prescribed.

Results The intervention was associated with a significant increase in the proportion of non-oxycodone users from 15% to 32% (17% difference; 95% CI 10 to 25), a decrease in total in-hospital oxycodone dose among users, and no change in the time to first oxycodone dose. The adjusted OR for being a non-oxycodone user associated with the intervention was 2.67 (95% CI 2.12 to 3.50). With the intervention, the proportion of oxycodone-free discharge prescription increased from 4.4% to 8.5% (4.1% difference; 95% CI 2.5 to 5.6) and the number of prescribed oxycodone pills decreased from 30 to 18 (−12 pills difference; 95% CI −11 to −13).

Conclusions Multimodal stepwise analgesia after cesarean delivery increases the proportion of oxycodone-free women during in-hospital stay and at discharge.

  • obstetrics
  • outcome assessment
  • health care
  • analgesics
  • opioid

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  • Contributors RL had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: RL, ER, JG. Acquisition and statistical analysis: RL, ER, BD, BS, XW, BC, CH, CW, JG. Interpretation of data: RL, JG. Drafting of the manuscript: RL, JG. Critical revision of the manuscript for important intellectual content: JA. Administrative, technical, or material support: BC. Study supervision: RL

  • Funding Support for this study was provided solely from institutional and/or departmental sources.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the Institutional Review Boards of Columbia University Irving Medical Center (New York, NY, USA) and of Montefiore Medical Center (New York, NY, USA) as part of quality assurance programs using analysis of computerized medical records. Waiver for informed consent was obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.