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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 September 3rd, 2020

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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 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:
  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:



  • 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.

Mark Zakowski


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


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


Dr. Khan is an Addiction Medicine specialist and Chief of Addiction Medicine consult-liaison 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.