Obstetrics and Gynecology

March 18, 2025

Annetta M. Madsen, M.D., a urogynecologic surgeon at Mayo Clinic in Minnesota, and colleagues published a study comparing a multimodal opioid-sparing pain management protocol to usual care following pelvic reconstructive surgery. The publication appeared in the American Journal of Obstetrics and Gynecology in 2024. Here, Dr. Madsen answers questions about findings from this study and, more generally, about postsurgical opioid reduction.

How did you become interested in postsurgical opioids?

Throughout my training and fellowship, I began to consider opioid use for pain control as a hammer-and-nail situation where adequate pain control had become equal to the use of opioids. However, opioids come with the risk of harm and unwanted side effects. There also had been a national push to reduce opioid prescriptions, which further influenced my interest.

During my time as a Mayo Clinic OB-GYN resident, I witnessed our leadership's implementation of a department-wide enhanced gynecologic surgery recovery protocol. I saw that a few thoughtful changes could significantly reduce pain and improve readiness for discharge and overall recovery. After my fellowship, I was in practice on my own. In that role, I continued to implement small evidence-based practice changes I noted were effective at opioid use reduction with the same or better pain control. When I returned to Mayo Clinic, some colleagues and I decided to implement these changes as a multimodal bundle of evidence-based, opioid-sparing practices as a quality improvement project. My fellow decided to lead this project as her fellowship thesis.

How did you design this opioid reduction study?

This retrospective study compared patients six months postintervention with opioid-sparing strategies and the new prescribing protocol with patients six months preintervention given usual care for minimally invasive pelvic reconstructive surgery.

What were your study's findings?

We found that prescribing opioids at hospital discharge based on what the patient required in the hospital following pelvic reconstructive surgery reduced the proportion of patients discharged with prescription opioids. In addition, we found no evidence of uncontrolled pain or increased healthcare professional workload with this strategy. During repeated talks about pain control with patients following surgery, we learned that patients were satisfied with how we controlled their pain.

How do patients feel about postsurgical opioids for pain control?

Addressing the topic of pain control has allowed more open discussion and shared decision-making with our patients about their recoveries.

I've found many patients don't want opioids. They don't want them in their homes. Other patients say opioids make them feel sick.

If a patient says to us, "I don't think that's what I'll need for my pain," we need to be willing to listen and discuss the patient's concerns.

Beyond pain, we also discuss any other fears the patient may have before surgery, including factors that impact pain, such as constipation.

Ultimately, the physician and patient must agree on a plan for managing pain and other potential side effects following surgery.

What are OB-GYN healthcare professionals' barriers to reducing opioid prescriptions postsurgically?

Here are some concerns expressed by OB-GYN colleagues:

• Fear that we're doing harm by inadequately treating our patients' pain.
• Worry that we will be inundated with inquiries about prescriptions while on call, undermining the ability to address OB-GYN emergencies.

How have you presented the postsurgical use of nonopioid pain relievers to your patients?

We've tried to protocolize our strategies so patients wouldn't feel like we were shooting in the dark, just trying different things to reduce pain. We also help them see there are many effective ways to manage pain beyond opioid use. However, if they are not working, we are certainly willing to use opioids. We are not trying to withhold opioids from people who need them; we are trying to treat pain with the least risks and side effects and avoid overprescribing opioids when unnecessary. We keep the door open for patients to call us if we undershot what they needed at discharge, so they never feel alone about pain control after surgery.

What does the multimodal pain medication protocol involve?

This protocol includes:

• Preoperative expectation setting regarding pain control.
• Perioperative enhanced recovery protocol.
  • Preemptive pain control.
  • Preemptive nausea management.
  • Early return to activity and regular diet.
• Postoperative.
  • Alternating ibuprofen or ketorolac and acetaminophen.
  • Abdominal or perineal ice packs.
  • Heat therapy.
  • Muscle relaxants.
• Postoperative discharge prescribing protocol based on inpatient use.

The protocol looks at what patients need in the hospital for adequate pain control after pelvic surgery, and then the surgeon prescribes accordingly at discharge. Some patients do require opioids. We found that patients who need opioids while admitted use an average of three opioid tablets posthospital. We also found that historically, we've overprescribed opioids.

For patients who need opioids in the hospital, we prescribe opioids for them using a tiered protocol based on inpatient use. For example, if patients only used two doses in the hospital, they may be sent home with three tablets. But if they used oxycodone around the clock, they may be sent home with 10 tablets. We don't feel we have to write a "just-in-case" prescription if a patient didn't use opioids in the hospital.

We tell these patients if they don't need the opioids, don't take them. We also let them know they can communicate with us if the three tablets are not enough.

What are the goals of this pain relief protocol?

The goal is not to get rid of opioids but to avoid sending patients home with unnecessary prescriptions. At the same time, we want patients to go home feeling confident they have what they need at their bedsides.

We work hard to balance the risks and benefits of the pain control we use.

What is critical for an opioid-reduction, multimodal pain medication protocol to be successful?

Early pain control is key to patients not requiring opioids down the road. Clear communication between patients and healthcare professionals is another key aspect of ensuring patients know what to expect. Patients must know what to expect for pain, have a plan in place and be confident they can connect with care if, for some reason, their pain is not adequately controlled.

Are there any patients who might especially need opioids after pelvic reconstructive surgery?

We found that patients traveling a long way for surgery at Mayo Clinic who need to travel back home may need us to go beyond the multimodal protocol to include more opioids. Also, if patients have a chronic opioid use history or cannot use NSAIDs, they are likely to need a more tailored approach and are not good candidates for our tiered prescribing protocol.

Do you have any additional input on opioid use after reconstructive pelvic surgery?

This is a challenging balance. Our society has come from a time of "everyone gets opioids after surgery." However, we want to move away from "just-in-case" opioid prescriptions. We need to consider the risk of excess opioid diversion for our patients and family members.

Yet, our protocol for prescribing pain medications for patients during hospital dismissal was meant to be a guide. There will always be exceptions and unique circumstances for some patients. We, as urogynecologic surgeons, need to be able to make those determinations wisely.

For more information

Selle JM, et al. A bundle of opioid-sparing strategies to eliminate routine opioid prescribing in a urogynecology practice. American Journal of Obstetrics and Gynecology. 2024;231:278.e1.

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