Consumer Reports: Use opioids with care during C-section recovery

Risk of taking too many painkillers after cesarean, new studies show


Women who give birth by cesarean section, or C-section, might go home from the hospital with far too many opioid painkillers, according to three studies published online this week in the journal Obstetrics & Gynecology.

Researchers say study subjects who were prescribed larger numbers of opioid pills were also more apt to use more of them -- potentially heightening their risk of addiction.

These studies didn’t look at whether there’s a link between the amount of opioids prescribed after a C-section and a heightened risk of dependency. But in March, the Centers for Disease Control and Prevention (CDC) reported that the larger an initial opioid prescription is -- the report focused on back, head, joint, and neck pain -- the greater the likelihood of continued opioid use a year later.

“These are addictive medications,” says Brian Bateman, M.D., chief of obstetric anesthesia at Brigham and Women’s Hospital, and lead author of two of the three studies. “For some patients, being exposed, even in the setting of appropriate treatment for pain, may precipitate an affinity for the drug that leads to subsequent chronic use and even abuse.”

Though the CDC notes that 25 percent of users show signs of addiction after three months, recent research suggests that physical dependence could start at the two-week mark. That can cause withdrawal symptoms such as anxiety, heightened pain, nausea, and sleeplessness if people abruptly stop the drugs.

And taking opioids for more than even a few days might be problematic. “Once you get past three days, your risk of dependency starts to rise,” says Bradley Martin, M.D., Pharm.D., head of the division of pharmaceutical evaluation and policy at the University of Arkansas, and one of the authors of the recent CDC report.

In the U.S. it’s standard practice to prescribe opioids such as oxycodone (OxyContin and generic) and hydrocodone (Vicodin and generic) to manage discomfort at home during C-section recovery.

According to Marvin M. Lipman, M.D., Consumer Reports’ chief medical adviser, opioids can be effective for such acute postsurgical pain but must be used with great care. In 2015, some 11,000 Americans died from overdoses of prescription opioids, according to the CDC.

Here’s what you need to know about using opioids safely while recovering from a C-section:

New moms getting too many pills

When Bateman’s team surveyed 615 women (at several medical centers) who’d filled opioid prescriptions after a recent C-section, the researchers found that the new mothers were often given more pills than they needed. Some 84 percent of women in the survey had leftover pills -- and most used only about half the painkillers they were prescribed.

But those who received more pills tended to use more pills. For example, women who were prescribed fewer than 30 pills took only about 15, and women prescribed 40 pills took about 32. (Almost all the prescriptions were for 5-mg painkillers.)

“When physicians prescribe a lot of opioid medication, patients feel as though they should be consuming a lot of medication,” Bateman says.

In fact, taking more pills didn’t appear to provide any additional pain-relief benefits. In both groups about 80 percent of the women said they were satisfied with their pain management.

What’s also worrisome is that 95 percent of the survey subjects who had leftover pills held onto them. And a second study published in Obstetrics & Gynecology this week detected a similar pattern: When researchers from Vanderbilt University looked at opioid use in 179 women after a C-section, they found that three-fourths of those who filled their prescriptions had leftover pills and that the vast majority held on to them. Sixty-three percent stored them in an unlocked location.

Keeping opioids around the house increases the chance that they could be ingested by someone they’re not prescribed for, or accidentally ingested by children. “This is leading to excess pills in the community, which are subject to misuse,” says Chad Brummett, M.D., director of pain research at the University of Michigan Medical School, who wasn’t involved in the new research.

One simple strategy might help

A third study published this week in Obstetrics & Gynecology, also from Bateman’s team, had more positive findings: When 50 women who’d recently had a C-section at Massachusetts General Hospital had a short discussion with their doctors before discharge, they were more likely to go home with smaller prescriptions.

In what’s called shared decision-making, the women talked with their doctors about expected pain levels during at-home recovery, how much opioid medication they might need, the drugs’ benefits and risks, and safe medication disposal.

Women who had that conversation asked for about 50 percent fewer pills than the 40 that were usually prescribed to C-section patients at that hospital.

Safe pain relief for C-section recovery

If you’re going to give birth, where does all this leave you? Bear in mind that not everyone needs opioid painkillers after a C-section. In fact, according to Bateman, the U.S. is one of the only countries where an opioid prescription is typical following a C-section. Still, it is major surgery, he says, and many women have significantly more pain after a C-section than they do after a vaginal birth.

If you opt to use an opioid, take these steps to make sure you get only as much medication as you need:

Plan ahead to go home with fewer pills. The shared decision-making program that Batemen’s team studied isn’t standard in all hospitals. But you can replicate it for yourself, says Orly Avitzur, M.D., Consumer Reports’ medical director, by creating a pain-management strategy with your doctor even before you have a C-section, if possible.

If your C-section isn’t planned, “Have a conversation with your doctor before you leave the hospital about managing your pain at home,” Avitzur says. “You should only need a few days’ supply of opioids before you switch to over-the-counter pain medication.”

But be aware that there is no clear consensus on optimal prescription size for C-section pain management at home. “Currently opioid prescribing and guidelines for patients are based on [the doctor’s] opinion or experience,” Brummett says.

Take opioids short-term only. According to the CDC, most people can transition to non-opioid painkillers just three days after surgery. Few people should need to take opioids for more than a week.

“Severe pain requiring opioids is common following joint replacement and abdominal surgical procedures but rarely lasts longer than three to seven days,” Lipman says. “Discharge prescriptions should cover that time period only (with longer use to be decided on a day-by-day basis). Such limited prescribing habits would assure against leftovers and prolonged use.”

Dispose of extra pills safely. During the brief time you’re using opioids, be sure to store them safely, preferably locked away. Afterward, instead of keeping leftover opioids, take them to an authorized drug take-back site. These are often located in pharmacies, hospitals, and police departments. You can find one here or here.

Additional options: Some Walgreens pharmacies offer anonymous drug drop-off kiosks. Other chains, such as CVS and Rite Aid, sell postage-paid envelopes for mailing leftover opioids to collection facilities. And the Drug Enforcement Agency runs drug take-back programs twice per year.

If you really can’t find any place to take or send your extra opioid medications, you can flush them down the toilet.

When you switch to OTCs, use them right. Your doctor should advise you on how to use OTCs most effectively. For example, Lipman says, acetaminophen (Tylenol and generic) may be used in tandem with nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin IB, and generic) or naproxen (Aleve and generic) under a doctor’s supervision. With acetaminophen, limit your intake to no more than 3,250 mg within 24 hours. And if you find that you’re reaching for NSAIDs for more than 10 days, ask your doctor for an alternative to reduce risks such as gastrointestinal bleeding. 

Ask about nondrug methods as well. A hot water bottle on your abdomen may help ease pain, for instance. And drinking plenty of fluids and returning to your normal diet as soon as possible can help prevent the constipation that often accompanies C-sections.