Author: Daniele Parise, M.D.
ASA Monitor 02 2018, Vol.82, 72-73.
“Epidural in room 19,” my attending told me. As I went through the patient’s history, she informed me that she had a history of opioid dependence and was being maintained on Suboxone® (buprenorphine and naloxone) during her pregnancy. I explained the risks of epidural anesthesia along with the formulation of the epidural infusion (bupivacaine and fentanyl mix). She then followed with a question that had me perplexed, “Will the fentanyl dose in the epidural infusion cause me to relapse?”
The prevalence of opioid abuse during pregnancy has more than doubled over the past 20 years. Parturients who struggle with opioid abuse or dependence are at increased odds of maternal death, placental abruption, increased length of hospital stay, oligohydramnios and overall blood product transfusions. Other negative outcomes included stillbirth, intrauterine growth restriction, premature rupture of membranes, preterm labor and cesarean deliveries.1 With the opioid epidemic worsening and increasing in this patient population, our job as anesthesiologists during labor and delivery becomes even more central amidst the current opioid epidemic. As anesthesiologists, can we (and should we) avoid commonly used narcotics associated with high abuse potential? Can our pharmacologic regimen be altered in high-risk population groups such as obstetric patients? In order to answer these questions, we need to re-examine the effects of narcotic abuse and how this may affect our delivery of anesthesia.
Parturients with a history of opioid abuse have an increased incidence of developing post-cesarean section surgical pain (PCSSP) and possibly have an increased risk of developing opioid induced hyperalgesia, complicating optimal treatment regimens. A prospective study describing the prevalence and risk factors for chronic pain following cesarean section showed that at three, six and 12 months, the incidence of PCSSP was 18.3 percent, 11.3 percent and 6.8 percent, respectively. Independent predictors of PCSSP at three months included higher average pain intensity on movement within 24 hours postoperatively, preoperative depression and longer duration of surgery.2 Putting all this into perspective, it seems that opioidtolerant parturients are at greatest risk of developing both acute and chronic pain. So what can we as anesthesiologists do to reduce these problems?
Karen S. Sibert, M.D., FASA, physician anesthesiologist and current president of the California Society of Anesthesiologists, describes a non-opioid analgesia approach as fundamental during the ongoing opioid epidemic in our country. In her article titled “Why this anesthesiologist says ‘no’ to fentanyl,” Dr. Sibert mentions the use of multimodal approaches to treating painful stimuli during and after surgery with avoidance of opioids.3 This approach can be especially important in the post-cesarean section patient with a history of opioid abuse. In addition to regional anesthesia techniques such as spinals and epidurals, other regional procedures like transversus abdominis plane (TAP) blocks represent a valuable strategy to reducing both acute and chronic pain in this subset of patients.4 Multiple studies have shown that TAP blocks reduce 24-hour VAS scores post cesarean section as well as increase the time to first analgesic medication administration. These blocks are easy to perform, with both short- and long-term benefits, including earlier ambulation, improved infant care and reduced post-operative complications. Non-opioid anesthesia/analgesia for cesarean sections represents a valuable strategy for this subset of patients. Should we be considering this in every parturient presenting for cesarean section with a history of opioid abuse?
With all the recent literature regarding opioid abuse, it is still common practice for anesthesiologist to administer opioids as first-line analgesia to these patients. We as physicians are partly responsible for fueling the opioid epidemic, and it is our duty to control this crisis.
“First, do no harm”
We must take a step back and think about if we are fulfilling this oath for these patients. There are other options in patients presenting with a history of opioid dependence. Maximizing non-opioid regimen, refraining from opioid-based epidural infusions and the utilization of other regional techniques (TAP blocks) in post-cesarean sections should be considered by all anesthesia providers for this subset of patients. We need to continue to individualize care for our patients, for that is what makes our field unique and what makes each of our encounters memorable to our patients.
Maeda A, Bateman BT, Clancy CR, Creanga AA, Leffert LR . Opioid abuse and dependence during pregnancy: temporal trends and obstetrical outcomes. Anesthesiology.2014:121(6):1158–1165.
Jim J, Peng L, Chen Q, et al. Prevalence and risk factors for chronic pain following cesarean section: a prospective study. BMC Anesthesiol. 2016;16(1):99.
Sibert KS. Why this anesthesiologist says “no” to fentanyl. KevinMD. October 26, 2017. https://www.kevinmd.com/blog/2017/10/anesthesiologist-says-no-fentanyl.html. Last accessed December 12, 2017.Pubmed Partial Author articletitle stitle
Mankikar M, Sardesai SP, Ghodki PS . Ultrasound-guided transversus abdominis plane block for post-operative analgesia in patients undergoing caesarean section. Indian J Anaesth. 2016;60(4):253–257.