Optimizing pain management post urogynecologic surgery with restrictive opioid protocol


A recent study suggests that restrictive opioid prescribing protocols post-urogynecologic surgery are as effective as standard protocols, emphasizing the importance of multimodal analgesia and outpatient follow-up for patient satisfaction.

Optimizing pain management post urogynecologic surgery with restrictive opioid protocol | Image Credit: © John Doe - © John Doe - stock.adobe.com.

Optimizing pain management post urogynecologic surgery with restrictive opioid protocol | Image Credit: © John Doe - © John Doe - stock.adobe.com.

Restrictive opioid prescriptions are noninferior to routine opioid prescriptions for patient satisfaction among women receiving minor and major surgery for prolapse and incontinence, according to a recent study published in the American Journal of Obstetrics & Gynecology.


  1. Restrictive opioid prescribing protocols post-urogynecologic surgery demonstrated noninferiority in patient satisfaction compared to standard protocols, suggesting that reducing opioid prescriptions did not negatively impact patients' overall satisfaction with pain management.
  2. The study reflects the broader concern of opioid over-prescription in surgical contexts, particularly in fields like general surgery and gynecology. This over-prescription is recognized as a significant contributor to the opioid crisis, with implications for postoperative pain management practices.
  3. While previous research has investigated opioid prescribing variations, this study uniquely focused on patient satisfaction within the context of an Enhanced Recovery After Surgery protocol. This underscores the importance of evaluating pain management strategies within comprehensive surgical recovery frameworks.
  4. Findings suggest that multimodal analgesia, involving combinations of non-opioid medications like acetaminophen and ibuprofen, effectively managed postoperative pain without a significant increase in patient-reported pain severity. This aligns with recommendations to optimize multimodal analgesia before resorting to opioid prescriptions.
  5. The study's conclusion supports the practice of discharging patients without opioid prescriptions when multimodal analgesia is optimized and outpatient follow-up is arranged. This has potential implications for refining postoperative pain management protocols, aiming to mitigate opioid-related risks while maintaining high levels of patient satisfaction and pain control.

Over 82,000 opioid overdose deaths per year have been reported in the United States as of January 2023, with opioid over prescription recognized as a major contributor to the opioid crisis. Data has indicated practitioners in general surgery and gynecology often excessively prescribe opioids to patients, even after low-risk procedures.

While prior research has found similar rates of satisfaction between reduced vs higher standard opioid prescriptions, there is little data evaluating patient satisfaction when using enhanced recovery after surgery (ERAS) protocol after urogynecologic surgery.

To evaluate patient satisfaction from a restrictive opioid prescribing protocol after urogynecologic surgery, investigators conducted a randomized controlled, noninferiority trial. Participants included patients aged 18 years and older receiving minor or major surgery for prolapse and incontinence.

Exclusion criteria included opioid abuse history, preoperative opioid use, a true allergy to 2 or more opioids, a contraindication to nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, receiving a concomitant nonurogynecologic surgery, having a surgery scheduled before a major federal holiday, and having an unanticipated laparotomy.

Patients with a Pain Catastrophizing Scale (PCS) of 30 or higher were also excluded, as high PCS scores are associated with increased pelvic floor symptom distress and impact. Participants were randomized to receive a standard or restrictive opioid prescribing protocol.

The standard protocol included 3 to 5 pills of 5 mg oxycodone for minor surgery and 5 to 10 pills for major surgery. The restrictive protocol discharged patients with only acetaminophen and ibuprofen. Patients in the restrictive protocol group were allowed to request an opioid prescription at discharge with a maximum of 10 pills.

As part of the ERAS protocol, all patients received a 7-day supply of 600 mg ibuprofen and 500 mg acetaminophen at discharge for use every 6 hours for 3 days and then as needed. Patients with contraindications to NSAIDs were only prescribed acetaminophen and vice versa.

A standardized perioperative pain control regimen using ERAS procedures was utilized across both study arms. A physician recorded postoperative phone calls related to pain issues. Additionally, patients tracked pain medication use and pain severity for 7 days in a diary.

The Surgical Pain Scales was used to measure pain levels. Patient satisfaction with pain control was measured as the primary outcome of the analysis at the postoperative visit. Secondary outcomes included 7-day pain control and opioid use and 6-week opioid refill and health care utilization.

There were 129 patients included in the final analysis, 64 in the standard arm and 65 in the restrictive arm. Patients were aged a mean 56 ± 12.3 years, 10.1% had contraindications to NSAIDs, 73.4% received major-level surgeries, and 26.6% received minor-level surgeries.

Of patients, 87.1% received same-day discharge. During discharge, a similar last pain score was reported between study groups, at a median of 3 in the standard arm and the restrictive arm.

Other than increased opioid usage in the study arm with a median 20 oral morphine milligram equivalents (MME) vs 5 MME in the restrictive arm, no differences were observed between groups. An opioid prescription was requested by 46.2% of the restrictive arm, most of whom requested opioids on the day of discharge.

During the postoperative visit, satisfaction was reported in 92.2% of the standard arm and 92.1% of the restrictive arm. The difference of -0.1% indicated noninferiority. Similar results were reported in the per-protocol analysis, with satisfaction rates of 90.3% in the standard arm and 97.1% in the restrictive arm. The difference of 6.7% also met noninferiority criterion.

For secondary outcomes, 23.4% of the standard arm called about pain vs 18.5% of the restrictive arm. Urgent office visits for pain-related complications were reported in 6.3% and 1.5%, respectively, and use of an adjunctive, nonopioid analgesic in 10.9% and 12.3%, respectively.

A median 37.5 opioid oral MMEs were prescribed in the standard arm in the first 7 days vs a median 0 MMEs in the restrictive group. Significant differences in pain severity were not reported between groups. Additionally, differences were not observed based on surgery level.

These results indicated no significant changes in patient satisfaction between standard and restrictive opioid prescription protocols. Investigators recommended surgeons discharge patients without an opioid prescription when multimodal analgesia is optimized and outpatient follow-up is arranged.


Yuan AS, Propst KA, Ross JH, et al. Restrictive opioid prescribing after surgery for prolapse and incontinence: a randomized, noninferiority trial. Am J Obstet Gynecol. 2024;230:340.e1-13. doi:10.1016/j.ajog.2023.10.027

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