番茄社区

Pain management for postpartum patients should be individualized in a stepwise approach, and a multimodal approach including acetaminophen NSAIDs to opioids, the American College of Obstetricians and Gynecologists (ACOG) said.

While ob/gyns can use any of the available pain medications to treat post-operative cesarean pain, parenteral or oral opioids should held in reserve for "breakthrough pain," reported the ACOG Committee on Obstetric Practice.

Shared decision making is key for these strategies, and patients prescribed opioids should also be counseled about the risk of central nervous system depression in both the woman and breastfeeding infant, they wrote in a to be published in Obstetrics and Gynecology.

At last month's ACOG annual meeting, Christopher Zahn, MD, vice president, practice activities for ACOG, said that ob/gyns often are blamed for being a major contributor to the opioid problem and are "targeted a bit inappropriately."

"There was no current guidance related to this -- it was mostly around anesthesia analgesia and epidurals -- so it's one of the things we clearly recognized we needed," Zahn told 番茄社区. "People learn pain management through training, but every specialty has its own approach."

The authors noted a "stepwise, multimodal approach" to pain was implemented by the World Health Organization (WHO), back in recommendations made in 1986 for the treatment of cancer pain. They specifically noted that if opioids are included, this type of approach allows for administration of lower doses of opioids.

For pain after vaginal birth, the authors recommend non-pharmacologic therapies, as well as "mild analgesics" if necessary. They cite "inconclusive" data from the , as well as a , about opioids for treating uterine cramping.

But they added that if a standard dose of NSAID is insufficient, a "multimodal approach" involving an NSAID, acetaminophen and a "milder opioid" can be a next step. For cesarean birth, they cite the potential use of "opioids that are in combination with either acetaminophen or an NSAID."

In terms of breastfeeding, the authors noted an April 2017 FDA label revision of all prescription medications containing codeine and tramadol, which stated that breastfeeding is not recommended due to potential opioid overdose for the infant. In light of this guidance, the authors recommended ob/gyns review the risks and benefits, including patient education regarding newborn signs of toxicity with the family if a codeine-containing medication is selected for post-partum pain management. They added that "duration of use of opiate prescriptions should be limited to the shortest reasonable course expected for treating acute pain."

The authors also cited a study in that found the median number of dispensed opioid tablets following cesarean birth was 40, but the number consumed was 20. But they also warned against underprescribing, emphasizing the importance of a shared decision making approach for each patient, as an "optimal" number of tablets or duration of therapy has yet to be identified.

Zahn cautioned that ACOG has been "very resistant to legislation interfering in the physician/patient relationship," such as efforts to limit the number of pills or number of days someone is prescribed pain medicine.

"Some women require more and some women require less, and we should have flexibility to adjust that, based on what the patient needs," he said.

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