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Codeine for postnatal analgesia: friend or foe? A re-audit of post caesarean section pain control following MHRA guidance
Board Board 1 / Wed 12:10, 11 May 2016

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Codeine for postnatal analgesia – friend or foe? A re-audit of post Caesarean section pain control following MHRA guidance

V Bell, T Petty, C Laxton

Background

The Medicines and Healthcare Products Regulatory Agency (MHRA) issued a drug safety update in June 2013, stating that codeine should not be used in breast feeding mothers, and the Food and Drug Administration (FDA) likewise cautioned its use in 2007.1,2 However, controversy exists whether it is reasonable that a single tragic but very rare event should change practice.3 Our postnatal prescribing guideline was changed in 2013 to oral morphine, where tolerated, as the sole opioid for all women post caesarean. Furthermore, following the concomitant MHRA update regarding cardiovascular safety and diclofenac there was a pharmacy-led trust wide change to ibuprofen as the preferred non-steroidal. Our re-audit aimed to investigate the effect of these ‘imposed’ changes.

Methods

After Clinical Audit Committee approval, we prospectively audited the pain score (VAS 0-10), satisfaction with postnatal analgesia, and side effects, on days 1 and 2 following Caesarean section, in 2009 and 2015 using the same standardised proforma.Standards were >95% women satisfied4, and >95% women with VAS 0-4. A comparison was made between women receiving spinal anaesthesia, with intrathecal diamorphine 300mcg, in each time period. Postnatal analgesia in 2009 comprised Paracatamol 1g and Diclofenac 50mg TDS (if not contraindicated), with PRN Codeine 30-60mg QDS and Morphine PO 10-20mg, versus Paracetamol 1g and Ibuprofen 400mg QDS, and Morphine PO 10-20mg in 2015.

Results

125 and 148 women were audited in 2009 and 2015 respectively.  112/125 (2009), and 126/148 (2015) women were available for interview on day 1, and 75/125, and 80/148 on day 2, and results were expressed as a percentage of these.

Non-steroidal anti-inflammatories (NSAIDs) are an important part of the postnatal analgesia regimen as they are proven to have an opioid sparing effect. In 2015 a greater percentage of patients not taking NSAIDs received 2 or more doses of opioid, compared to patients taking NSAIDs. Overall 84% were prescribed NSAIDS in 2015 versus 90% in 2009.

Women were less satisfied with their analgesia in 2015, 88% vs. 94% in 2009, with 9% neutral and 5% dissatisfied. Side effects were similar in 2009 (32% nausea, 20% vomiting, 55% itch) as compared to 2015 (35%, 25%, 59% respectively).

Discussion

The results of our re-audit are disappointing and demonstrate higher pain scores, and less satisfaction after our ‘imposed’ changes’. We suspect the reasons are multifactorial and include the decreased effectiveness of ibuprofen to diclofenac (despite QDS dosing), with only 84% vs 90% prescribed NSAIDS overall,  the shorter duration of oral morphine and need for more frequent dosing, and perhaps the reluctance of women to continue taking morphine on day 2. Busy workloads on postnatal wards led to delay in regular medication timing and receiving extra doses of oramorph. Changes in patient expectations, earlier mobilisation and discharge after uncomplicated routine caesareans likely led to more complex women, with higher pain scores, being included in the 2015 audit. 

Recommendations include:

•Introducing dihydrocodeine 30mg PRN as an alternative to oramorph
•Exploring the use of self- administered analgesic packs in hospital
•Ensuring ibuprofen prescribed as soon as possible, if contraindication resolves
•Ensure education of women regarding  expectations post caesarean

References:

1.Medicines and Healthcare products Regulatory Agency. Codeine: restricted use as analgesic in children and adolescents after European Safety Review. Drug Safety Update June 2013, vol 6, issue 11.
2.Food and Drug Administration Patient Safety News. Rare side effects of codeine in nursing mothers. November 2007
3.Halder S, Russell R, Quinlan J. Codeine and breast-feeding mothers. Int J Obstet Anesth 2015; 24: 5-7

Lucas N, Pickering E, Plaat F. Section 8.11 – Pain relief after caesarean section. The Royal College of Anaesthetists. Raising the Standard: a compendium of audit recipes for continuous quality improvement in anaesthesia. 3rd Edition 2012. 

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