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Best practice №15

Utilize shared decision making to tailor post-procedure pain control

by Mark Zakowski, Pamela Flood, Tipu V. Khan

Last updated March 12th, 2020

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Overview

Individual patients often fear the loss of autonomy in a hospital setting and, knowing their increased tolerance for medication, fear for their ability to relieve their pain. 

Why we are recommending this best practice

There is extensive variability in the needs of women with OUD for pain control over and above their maintenance therapy. Shared decision making has been shown to reduce overall opioid use.

Strategies for implementation

  • For severe pain, develop policies for maintenance of an epidural analgesia catheter during the first few postpartum days. These policies will limit the dependence on pain medications to which the mother may have developed tolerance. 

  • Consider Transverse Abdominis Plane (TAP) block, Quadratus Lumborum Block (QL2), or paravertebral blocks/catheters with the consultation of an anesthesiologist. Create facilities, training, and procedures for providers to maintain these catheters and advise patients on their benefits and use. 

  • Schedule adjuvant medications including non-steroidal anti-inflammatory medications and acetaminophen to reduce the need for opioid dose escalation. Develop procedures and training for the administration of other adjuvant medications including gabapentin or pregabalin, or short-term ketamine in consultation with and under the supervision of an anesthesiologist. 

  • Consider local analgesic and other analgesic patches for postsurgical pain.   

  • Do not routinely give opioids above maintenance doses for vaginal births.  

Deep dive

What is shared decision making and why does it matter? Shared decision making occurs when the patient is considered a critical part of the team. Two axioms are important to shared decision making: “No decision about me without me” and “this patient is the only patient.” Together, this means each patient is an individual and should be treated as such, and their own individual values and preferences should be the starting point for all conversations. When done right, shared decision making leads to improved quality of care, improved outcomes, and better patient experience. 

The basic components of shared decision making are:
  1. Seek your patient’s participation
  2. Help your patient explore and compare treatment options
  3. Assess your patient’s values and preferences
  4. Reach a decision with your patient
  5. Evaluate the decision 

More information and an entire toolkit on the “SHARE Approach” can be found on the ARHQ website at:  https://www.ahrq.gov/health-literacy/curriculum-tools/shareddecisionmaking/index.html

Resources

References

  • Ansari J, Carvalho B, Shafer SL, Flood P. Pharmacokinetics and Pharmacodynamics of Drugs Commonly Used in Pregnancy and Parturition. Anesthesia and analgesia. 2016;122(3):786-804.

Mark Zakowski

MD, FASA

Dr. Mark Zakowski is Chief of Obstetrical Anesthesiology, Fellowship Director and Professor of Anesthesiology at Cedars-Sinai Medical Center in Los Angeles.  He has also served as President of the California Society of Anesthesiologists, the Society for Obstetric Anesthesia and Perinatology, and numerous committees at the state and national level as an advocate for pregnant women and their newborns. Dr. Zakowski has authored many chapters, articles and a book for pregnant women about cesarean sections.

Pamela Flood

MD, MA

Dr. Pamela Flood is Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University. Her research interests include prevention and reduction of pain and opioid use in women after delivery. She divides her clinical time between labor and delivery and her outpatient pain management clinic. She clinical work is directed toward compassionate weaning of high dose opioids and management of pelvic pain syndromes.

Tipu V. Khan

MD, FAAFP, FASAM

Dr. Khan is an Addiction Medicine specialist and Chief of Addiction Medicine consult-liason service and outpatient specialty clinic at Ventura County Medical Center. He is the medical director of Prototypes Southern California which has hundreds of residential treatment beds as well as medical-withdrawal (detox) beds throughout Southern California. Dr. Khan is the Medical Director of the Ventura County Backpack medicine group, and Primary Care Hepatitis C Eradication Project. His niche is managing SUD in pregnancy and is a national speaker on this topic.