Contraceptive Pearl: Considerations for Pain Management for In-Office Gynecologic Procedures for People with Substance Use Disorder
Written by Keri Garel, Meera Nagarsheth, Lakshmi Sundaresan (All authors equally contributed to this work.)
Patient-centered pain management that prioritizes bodily and reproductive autonomy is essential to centering reproductive justice in the provision of reproductive health care, especially given the history of reproductive violence and coercion towards structurally marginalized communities. This article highlights pain management considerations for patients with substance use disorder (SUD) undergoing in-office gynecologic procedures, as well as those taking medication for SUD. Centering trauma-informed care, abolition, and harm reduction in addition to reproductive justice and patient autonomy as praxes are particularly important to providing equitable care for this population.
Physiological changes associated with SUD can affect pain perception and the response to various pain medications (Table 1). Our recommendations for patients with SUD undergoing non-abortion gynecologic procedures are extrapolated from those for procedural abortion care and for non-gynecologic procedures.1-3
Patients with a history of SUD may experience hyperalgesia and require higher doses of pain medications than patients without SUD, but this increased pain sensitivity is not always the case.4 A multimodal approach to procedural pain control represents an avenue for customizing pain control options specific to the patient’s history and situation, with incorporation of nonpharmacological support as a powerful adjunct (e.g., hot packs, distraction, trauma-informed approach). Multimodal analgesia aims to target multiple different pain receptors or pain-perception receptor pathways to achieve adequate pain control.
For in-office cervical or intrauterine procedures (e.g., endometrial biopsy, IUD insertion, LEEP), NSAIDs combined with local anesthesia (e.g. topical lidocaine; intracervical or paracervical block) are recommended for intraprocedural pain management.1 NSAIDs and acetaminophen are effective in postprocedural pain management.1,2 Compared to placebo, gabapentin does not reduce pain scores during uterine aspiration but has been shown to overall decrease post-procedural opioid use.5
Toxicology testing is not predictive of acute intoxication, capacity to consent to a procedure, risk of sedation, or procedural outcomes.6 Patients can safely continue maintenance medications when having a procedure.
Table 1 offers an overview of various classes of substances with examples, their receptor, mechanism of action, and understood impact upon pain perception.
Table 1:
| Substance(s) | Drug Class | Primary Receptor / Target | Mechanism of Action | General Effect of Drug Class on Pain Perception |
| Heroin, Morphine, Fentanyl, Oxycodone | Opioids | µ-opioid receptor (MOR) | Agonist; inhibits GABA release, disinhibiting dopamine neurons. | Blocks pain signals at the spinal cord and activates the descending inhibitory pathway. Also reduces the emotional distress of pain. |
| Cocaine | Stimulants | Dopamine Transporter (DAT) | Blocks reuptake of dopamine, norepinephrine, and serotonin. | Temporarily “masks” pain through the fight-or-flight response by increasing norepinephrine, though this is often followed by hypersensitivity to pain. |
| Amphetamine, Methamphetamine | Stimulants | DAT, NET, SERT, and VMAT2 | Reverses transporter flow, pumping neurotransmitters into the synapse. | |
| Benzodiazepines, Barbiturates | Depressants | GABAA receptor | Positive allosteric modulator; increases inhibitory chloride conductance. |
Reduces the muscular tension and anxiety associated with acute pain. Anxiolytic effect. Not for use as primary analgesia.
|
| Alcohol (Ethanol) | Depressants | GABAA, NMDA, 5-HT3 | Potentiates GABAA(inhibitory) and inhibits NMDA (excitatory) receptors. | |
| Marijuana (THC) | Cannabinoids | Cannabinoid CB1 and CB2 | Agonist; modulates release of both excitatory and inhibitory neurotransmitters. | Reduces “inflammation” via CB2. Alters the threshold of pain neurons in the brain and spinal cord via CB1. |
| Nicotine | Nicotinics | Nicotinic Acetylcholine (nAChR) | Agonist, particularly at the α4β2 subtype in the ventral tegmental area (VTA). | May provide short-term analgesia but contribute to long-term hyperalgesia |
| LSD, Psilocybin, DMT | Hallucinogens | Serotonin 5-HT2A receptor | Partial agonist; alters cortical perception and mood. | Do not block pain signals physically, but can radically alter the psychological interpretation and “meaning” of pain. |
| Ketamine, PCP | Dissociatives | NMDA receptor | Antagonist; blocks excitatory glutamate signaling. | Blocks glutamate (the main excitatory signal). This prevents the “wind-up” phenomenon where pain becomes amplified and chronic. |
| MDMA (Ecstasy) | Entactogens | Serotonin Transporter (SERT) | Primarily triggers massive release and blocks reuptake of Serotonin (5-HT). | Unknown |
Box 1 summarizes considerations from the University of British Columbia for achieving appropriate analgesia in patients with SUD.7
Box 1: Considerations to Achieving Appropriate Analgesia (in any patient but with considerations for patients with SUD):
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As with all patients, incorporate shared decision-making when determining the setting for a procedure and the methods of procedural pain management. Center principles of reproductive justice, trauma-informed care, and harm reduction in approaching the discussion of pain control. Unfortunately, there is no singular unifying protocol for how to treat patients with SUDs, but only the recognition and recommendation that, oftentimes, the referenced threshold “maximum” and “minimum” dosages for achieving sedation may be at odds with the patient experience. If unable to provide adequate pain management in the office, consider referral for a procedure with moderate or deep sedation. Hospital-based care may not be required, as most patients who use substances are still able to safely receive moderate or deep sedation in ambulatory surgical centers.
RHAP Resources:
Your Birth Control Choices Fact Sheet
Options to Manage Pain for Gynecologic Procedures
Download and print our resources for free from our website or visit our store to buy physical copies!
Partner Resources:
Reproductive Health Hotline (ReproHH): A free, confidential phone service (1-844-737-7644) offering evidence-based clinical information for healthcare providers across the US who have questions related to sexual and reproductive health.
PICCK: Substance Use Disorder and Family Planning Care
TEACH Abortion Training Curriculum, 8th Edition: The revised 8th Edition of the TEACH Abortion Training Curriculum is an updated and interactive curriculum, with tools to train new reproductive health providers to competence. See particularly pages 126-127
Sources:
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