Impact of individualized opioid protocols on post-cesarean discharge prescriptions

Consensus on optimal prescribing of opioids at discharge following cesarean delivery remains limited. Since inpatient opioid use is a strong predictor of outpatient need, individualized approaches may improve prescribing accuracy. The optimal individualized prescribing protocol for post-cesarean pain management at discharge is unknown. While multiple studies have demonstrated benefit with individualized protocols, direct comparison of different protocols has not yet been demonstrated. This study evaluated the modeled application of four individualized prescribing protocols (based on inpatient opioid consumption) on post-cesarean discharge prescriptions compared to actual prescribing patterns.

This retrospective cohort study included all patients ≥18 who underwent cesarean delivery from September 1 to December 31, 2023 at a single tertiary academic center. Inpatient opioid use was abstracted from electronic medical records and used to calculate discharge prescriptions based on the following previously published protocols: Bleicher et al. (2024), Osmundson et al. (2018, 2022), and the Prescription After Cesarean Trial (PACT). These modeled prescriptions were compared to the actual prescriptions received at discharge. The primary outcome was total dose prescribed in morphine milligram equivalents (MME); secondary outcomes included number of tablets prescribed and number of patients receiving a prescription at discharge.

A total of 197 patients were included. There were 124 primary cesarean deliveries (63%) and 73 repeat cesarean deliveries (37%). Of these, 186 (94%) received an opioid prescription at discharge and had a median total dose of 75 MME. Total MME prescribed at discharge decreased among >60% of patients using the Bleicher, Osmundson 2022, and PACT protocols, but increased among 64% of patients using the Osmundson 2018 protocol. Compared to actual prescribing, both Bleicher and PACT models reduced the proportion of patients receiving an opioid prescription by 38%, while both Osmundson models resulted in a 6% increase in patients receiving prescriptions.

Within the same population, the impact of individualized post-cesarean opioid prescribing protocols varied widely. These findings demonstrate that the choice of individualized prescribing model may meaningfully influence discharge prescribing and highlight the need for prospective comparative studies incorporating patient-reported pain and satisfaction outcomes to identify the optimal approach.