SUMMARY POINTS

Pain perception includes both physical and psychosocial elements and is best managed with both preemptive and multi-modal approaches.
Studies show disparities in pain management by race and for people with substance use disorder, raising important opportunities for clinicians to pause and evaluate their own biases (See Ch 2: Bias) and to prioritize measures that reduce pain.
Non-pharmacological methods of pain management offer low risk components of a multi-modal approach and allow for individualized care.
Paracervical block helps reduce uterine aspiration pain and is recommended routinely. There are many variations on technique.
Oral NSAIDs are a low risk component of a multi-modal approach and are recommended routinely. Acetaminophen is also low risk and likely beneficial.
Anxiolytics oral opioids may be given individually or together prior to uterine aspiration, although the latter may cause nausea with limited benefit.
Intravenous pain management may be chosen if monitoring and staffing are available; and patients may require respiratory support.
Individuals who regularly use opioids or have opioid use disorder on medication assisted therapy should continue their medications prior to a procedure and may require higher doses of pain medications. Substance use should not impact a clinician’s usual assessment of capacity for informed consent.

Universal pre-procedure antibiotic prophylaxis before uterine aspiration is well supported by available evidence.
Safety will be improved by attention to allergies, concurrent medications, conditions that compromise respiratory status, recommended dose limits, and reversal agents.
Emergency management simulations and supplies should be regularly reviewed.

In addition to both non-pharmacologic support and multimodal pain management, it helps to involve the person in decisions around the procedure, practice gentle and slow procedural technique, and use a reassuring tone throughout.

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