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.
Overview
Why we are recommending this best practice
There is extensive variability in the needs of women with opioid use disorder (OUD) for pain control over and above their maintenance therapy.
Shared decision making is a dynamic process during which the provider and patient engage in an informed discussion to make health related choices that are best for the patient and in alignment with the patient’s personal values (refer the Resources section of this Best Practice for more information), Shared decision making has been shown to reduce overall opioid use.
Strategies for implementation
- For each patient with OUD, engage in an open and honest discussion about pain control and encourage shared decisions about pain management.
- 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:
- Seek your patient’s participation
- Help your patient explore and compare treatment options
- Assess your patient’s values and preferences
- Reach a decision with your patient
- 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
- Ramsay Sedation Scale: Designed for use in critically ill adults that has broad applicability in evaluation of the range between agitation and over sedation in response to sedatives and analgesics.
- COWS: A clinical opioid withdrawal scale designed to monitor signs of opioid withdrawal.
- Considerations for Administration of Buprenorphine and Methadone.
- Considerations for Treatment of Opioid Use Disorder in Pregnancy.
- “SHARE Approach” AHRQ. Shared Decision Making.
References
- Ansari J, Carvalho B, Shafer SL, Flood P. Pharmacokinetics and pharmacodynamics of drugs commonly used in pregnancy and parturition. Anesth Analg. 2016;122(3):786-804. doi: 10.1213/ANE.0000000000001143.