Expert Q&A: Improving opioid management in maternal health

Alex Friedman Peahl, M.D., M.Sc., is an assistant professor of obstetrics and gynecology at Michigan Medicine and a member of the U-M Institute for Healthcare Policy and Innovation (IHPI). She is the chair of the American College of Obstetricians and Gynecologists (ACOG) Redesigning Prenatal Care Initiative and the co-director of the Partnering for the Future clinic at the U-M Health Von Voigtlander Women’s Hospital, specifically designed for patients with opioid use disorder, substance use disorder, and chronic pain with long-term opioid use. She is the lead for the new national Creating Optimal Pain Management for Tailoring Interventions after Childbirth (COMFORT) guidelines for peripartum pain management.

Peahl's research focuses on improving the effectiveness, efficiency, and equity of reproductive health care by developing, studying, and disseminating high-quality maternity care interventions. A nationally recognized prenatal care redesign expert, Peahl has completed seminal studies and thought pieces on how to best incorporate patients’ preferences and needs into prenatal care plans. 

Recently, Peahl and colleagues conducted four studies evaluating best pain management practices in the peripartum period, with the goal of understanding and reducing the risks of opioid prescribing during and after pregnancy.

In this Q&A, she discusses the findings from these studies and their overall implications for maternal health policy and practice.
 

What are the key findings of your studies?

Our first study, published in Maternal and Child Health Journal, explored the experience of postpartum pain management in patients who are often excluded from these types of studies, specifically patients with opioid use disorder and those with chronic pain who have received opioids in the year prior to birth. 

We found that over a third of the patients had poor pain control in the postpartum period and up to a week after discharge, with poor pain control rated higher among those with cesarean versus vaginal birth. In the qualitative work of this study, we learned that patients did not, in many cases, feel that their pain management was optimal. Several factors were shown to help patients with their recovery from birth postpartum, specifically opioid-sparing protocols and better preparation for birth. This study also highlighted patients with opioid use disorder’s experiences with Child Protective Services (CPS), emphasizing the importance of preparing patients for CPS interactions during postpartum care.

Our other studies looked at prescribing patterns. Our study, published in the American Journal of Perinatology, found that patients with chronic pain received larger prescriptions than other groups. In contrast, patients with opioid use disorder received opioid prescriptions less frequently than the general population. In our Women’s Health Issues study, we found significant variation in both prescribing rates and prescription size across vaginal and cesarean births, with much of that variation attributable to providers and hospitals and more variation linked to providers and hospitals for vaginal birth than for cesarean birth.

In our study published in AJOG Global Reports, we aimed to better understand patients’ experiences of postpartum pain management in the setting of an opioid-sparing protocol, which involves scheduled non-opioids and limited opioid prescribing.  We also wanted to look at opioid utilization, and how pain affects recovery and early parenthood.

We found that, following cesarean birth, approximately 60 percent of our patients felt that their pain was well managed with acetaminophen and ibuprofen alone. In spite of this, 80 percent of patients were discharged with an opioid prescription. Of those patients who utilized an opioid in their post-discharge recovery, a median of eight tablets was used at home of the 20 tablets prescribed. We also learned that the majority of patients reported feeling completely recovered by the six-week postpartum mark, but many also felt that pain affected key components of early recovery, including the ability to bond with the baby, breastfeed, and care for their newborn.

Taken together, what do these four studies suggest?

These studies together document the unacceptable variation in postpartum pain management across hospitals, providers, and patients. These findings also provide some clues on how we can better approach pain management in the postpartum period. Opioid-sparing pain management is a critical foundation that should be offered to all patients as a way to lower baseline pain, opioid consumption, and help patients move through recovery. 

Our work also shows that it is important to consider individual factors, whether that is the procedure or chronic conditions patients are coming into pregnancy with, such as opioid use disorder and chronic pain, and their pain needs. We've come to refer to this as a standardized choice: everyone should receive the same options, but that those options be tailored based on individual factors.

What I love about working in the postpartum pain management space is that it is a problem we can fix. We know that when we implement opioid-bearing protocols, opioid use goes down, pain management is excellent, and patients are really satisfied with their care. 

What are the policy and practice implications of this work? 

Our findings are informing new work funded by an FDA grant to develop peripartum pain management guidelines, called Creating Optimal Pain Management for Tailoring Interventions after Childbirth (COMFORT), for the general population as well as specific subgroups. From a policy perspective, insights from studies like these are vital in bringing the patient voice into tailored postpartum pain management strategies. 

Prior to the work funded by the FDA, postpartum pain management guidelines had not specifically included a callout for patients with complex pain, opioid use disorder, or chronic opioid exposure before birth. Studies like ours help to provide context to the kind of care individualization we need within these policies. This can also inform how our healthcare system interfaces with public service organizations, and how to improve coordination across the pregnancy episode.

The results from our Women’s Health Issues study also suggest that there are differences in provider behavior and hospital policy that account for much of the variation in prescribing rates. This is a very optimistic finding in that we can do better for our postpartum patients, reducing the risks of opioid prescribing while also maintaining good pain control.
Our work demonstrates the efficacy of opioid-sparing pain management after cesarean birth and highlights how this is a critical part of postpartum pain management, as well as a way to reduce postpartum opioid consumption.

And overall, our findings also highlight the importance of maternal support in the postpartum period during recovery. Half of our patients noted that pain influenced their ability to care for their newborn. We are thinking about how we can provide extra scaffolding and support for birthing patients as they are recovering from major abdominal surgery.

How will this work help those who carry pregnancies to be safer around the use of opioids?

In birthing patients with opioid use disorder in pregnancy, medication for opioid use disorder (MOUD, e.g., buprenorphine, methadone) is the recommended treatment. Our findings can help improve the quality of pain management for that population as they transition to the postpartum period. We know that poorly controlled pain can be a risk factor for return to substance use postpartum. Having more information on how to support this group is very important for safety as they transition into parenthood. 

Similarly, for patients either managing recovery or managing chronic pain or chronic opioid exposure in pregnancy, pain can be more difficult to control. Understanding a patient’s pain management requirements, both in preparation for the postpartum period and additional measures to keep them comfortable postpartum is important for mental health, depression, anxiety, ability to parent, and maternal-infant bonding.

Overall, our work aims to help patients at the time of childbirth receive excellent pain management that allows them to seamlessly transition to parenthood. People who have a cesarean birth are undergoing a major abdominal surgery at the same time that many are becoming parents. Similarly, patients undergoing vaginal birth may require perineal tears and other sources of pain while caring for their newborn. It is critical that we help patients to do so comfortably with excellent pain management. 

At the same time, we know that one in 75 birthing patients who receive an opioid prescription go on to develop new persistent opioid use or continued opioid refills in the year postpartum. Helping to reduce the risk of that initial opioid prescription is important. We hope that our work helps to reduce unwarranted variation and excess opioid prescribing while ensuring all birthing people have safe, pain management that supports their transition to parenthood.

Papers cited & additional authors: 

1. Use of Opioid-Sparing Protocols and Perceived Postpartum Pain in Patients with Opioid Use Disorder and Chronic Prenatal Opioid Exposure. Matern Child Health J 27, 1416–1425 (2023). DOI: 10.1007/s10995-023-03710-8
   
   Additional authors are Courtney Townsel, Sanaya Irani, Buu-Hac Nguyen, Alexander Hallway, Clayton Shuman, Jennifer Waljee, and Kaitlyn Jaffe. Shuman and Waljee are members of IHPI.
    
2. Postpartum Opioid Prescribing in Patients with Opioid Use Prior to Birth. Am J Perinatol 2024; 41(S 01): e1459-e1462. DOI: 10.1055/s-0043-1767816 
   
   Additional authors are Emma Keer, Alexander Hallway, Brooke Kenney, Jennifer Waljee, and Courtney Townsel.
    
3. Variation in Opioid Prescribing After Vaginal and Cesarean Birth: A Statewide Analysis. Peahl, Alex F. et al. Women's Health Issues, Volume 33, Issue 2, 182 - 190. DOI: 10.1016/j.whi.2022.08.007
   
   Additional authors are Daniel Morgan, Elizabeth Langen, Lisa Kane Low, Chad Brummett, Yen-Ling Lai, Hsou-Mei Hu, Melissa Bauer, and Jennifer Waljee. Morgan, Langen, Low, Brummet, and Waljee are members of IHPI.
    
4. Pain and Recovery Following Cesarean Delivery in Patients Receiving an Opioid-Sparing Pain Regimen. AJOG Glob Rep. 2023 Jun 24;3(3):100248. DOI: 10.1016/j.xagr.2023.100248 
   
   Additional authors are Alexander Hallway, Brooke Kenney, Emma Lawrence, Roger Smith, Chad Brummett, and Jennifer Waljee.