Continuous Epidural Hydromorphone Infusion for Post-Cesarean Delivery Analgesia in a Patient on Methadone Maintenance Therapy: A Case Report

Mellany A Stanislaus,1 Joseph L Reno,1 Robert H Small,1 Julie H Coffman,2 Mona Prasad,3 Avery M Meyer,4 Kristen M Carpenter,4 John C Coffman1 1Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 2Department of Internal Medicine, Riverside Methodist Hospital, Columbus, OH, USA; 3Department of OBGYN, Riverside Methodist Hospital, Columbus, OH, USA; 4Department of Psychiatry, The Ohio State University Wexner Medical Center, Columbus, OH, USACorrespondence: John C CoffmanDepartment of Anesthesiology, The Ohio State University Wexner Medical Center, Room N-411 North Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USATel +116142938487Fax +116142938153Email john.coffman@osumc.eduAbstract: The prevalence of opioid use disorder (OUD) in the United States has more than quadrupled over the past two decades. This patient population presents a number of challenges to clinicians, including difficult pain management after surgical procedures due to the development of opioid tolerance. Significantly greater opioid consumption and pain scores after cesarean delivery have been reported in patients with OUD compared to other obstetric patients. A multi-modal analgesic regimen is generally recommended, but there are few well-established pain management strategies after cesarean delivery specific to patients with OUD. We present the case of a patient with OUD maintained on daily methadone that received a continuous epidural hydromorphone infusion for post-cesarean analgesia, a technique not previously reported in obstetric patients and only rarely described for patients undergoing other surgical procedures. The patient received epidural anesthesia for cesarean delivery, and after surgery, the epidural catheter was left in place for the epidural hydromorphone infusion, initiated at 140 mcg/hr and continued for approximately 40 hrs. This strategy reduced her average daily oral opioid consumption by 97%, reduced self-reported pain scores