Author Credentials

Kevin D. White MD, MEd Shirin Azadi BS Nadim Bou Zgheib MD Brenda L. Mitchell MD






Prescription drug abuse presents a significant challenge to the management of post operative pain.Pain control amongst the opioid addicted patient can be especially challenging. We aimed to improve pain control after caesarian delivery with enhanced recovery in patients who are on buprenorphine medication-assisted therapy for the treatment of opioid addiction.

Materials and Methods:

We conducted a pilot study by implementing a protocol using liposomal bupivacaine injected at the time of cesarean delivery. Patients were then given 500mg acetaminophen every 4 hours, 800mg ibuprofen every 8 hours and 0.3mg IV buprenorphine every 6 hours as needed. The patients’ maintenance dosing of buprenorphine was divided into doses throughout the day. In addition, patients were ambulated 4 hours after surgery and had their catheter removed from their bladder as soon as they could safely ambulate. Eleven patients were prospectively recruited and then compared to a retrospective sample of seventeen patients.


Patients in the treatment group reported 27% lower pain scores (p


Our enhanced recovery protocol is an effective alternative to traditional pain control and is associated with a significant reduction in both pain scores and use of breakthrough IV buprenorphine as well as lower charges.

Conflict(s) of Interest


References with DOI

1. Centers for Disease Control and Prevention. Injury Prevention and Control: Opioid Overdose. Drug Overdose Death Data. 2016. Accessed March 2017.

2. Opioid abuse, dependence and addiction in pregnancy. Committee Opinion No. 524. American College of Obstetricians and Gyneoclogists. Obstet Gynecol. 2012;119;1070-6. Reaffirmed 2016. https://doi.org/10.1097/aog.0b013e318256496e

3. Opioid Dose Calculator. [March 2017]. Agency Medical Directors Group. Available from http://www.agencymeddirectors.wa.gov/Calculator/DoseCalculator.htm.

4. Equivalency Table. [March 2017]. Stanford School of Medicine:Palliative Care. Available from https://palliative.stanford.edu/opioid-conversion/equivalency-table.

5. Opilphant SS, Jones KA, Want L, Bunker CH, Lowder JL. Trends over time with commonly performed obstetric and gynecologic inpatient procedures. Obstet Gynecol. 2010;116(5);926-931. https://doi.org/10.1097/aog.0b013e3181f38599

6. Wrench IJ, Allison A, Galimberti A, Radley S, Wilson MJ. Introduction of enhanced recovery for elective caesarean section enabling next day discharge: a tertiary centre experience. International Journal of Obstetric Anesthesia. 2015;24:124-130. https://doi.org/10.1097/01.aoa.0000482591.88381.e4

7. Dickson EL, Stockwell E, Geller MA, Vogel RI, Mulany SA, Ghebre R, et al. Enhanced recovery program and length of stay after laparotomy on a gynecologic oncology service: a randomized control trial. Obstet Gynecol. 2017;129(2):355-362. https://doi.org/10.1097/aog.0000000000001942

8. Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J, et al. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg. 2011;146:571-7. https://doi.org/10.1001/archsurg.2010.309

9. Dickson E, Argenta PA, Reichert JA. Results of introducing a rapid recovery program for total abdominal hysterectomy. Gynecol Ovsts Invest. 2012;74:21-5. https://doi.org/10.1159/000328713

10. Nelson G, Kalgera E, Dowdy SC. Enhanced recovery pathways in gynecologic oncology. Gynecol Oncol. 2014;135:586-94. https://doi.org/10.1016/j.ygyno.2014.10.006

11. Kalogera E, Makkum-Gamez JN, Weaver AL, Moriarty JP, Borah BJ, et al. Abdominal incisions injection of liposomal bupivicain and opioid use after laparotomy for gynecologic malignancies. Obestr Gynecol. 2016;128(5):1009-1017. https://doi.org/10.1097/aog.0000000000001719

12. Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. Enhanced recovery pathways for improving outcomes after minimally invasive gynecologic oncology surgery. Obstet Gynecol. 2016;128(1):138-44. https://doi.org/10.1097/aog.0000000000001466

13. Exparel ® [package insert]. Pacira Pharmaceuticals, Inc., San Diego, CA; 2016.

14. Nelson G, Dowdy SC, Lasala J, Mena G, Bakkum-Gamez J, Meyer LA, Iniesta MD, Ramirez PT. Enhanced recovery after surgery (ERAS ®) in gynecologic oncology. Practical considerations for program development. Gynecologic Oncology. 2017;147(3)617-620. https://doi.org/10.1016/j.ygyno.2017.09.023

15. Jarlenski M, Bodnar L, Kim J, Donohue J, Krans E, Bogen D. Filled prescriptions for opioids after vaginal delivery. Obstet Gynecol. 2017;129(3):431-437. https://doi.org/10.1097/aog.0000000000001868

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