State of the art opioid-sparing strategies for post-operative pain in adult surgical patients

ABSTRACT

Introduction: There are various important implications associated with poorly controlled postoperative pain in the adult surgical patient – this includes cardiopulmonary complications, opioid-related side effects, unplanned hospital admissions, prolonged hospital stay, and the subsequent development of chronic pain or opioid addiction. With the ongoing national opioid crisis, it is imperative that perioperative providers implement pathways for surgical patients that reduce opioid requirements and pain-related complications.

Areas covered: In this review, the authors discuss the components of a multimodal opioid-sparing analgesia pathway as it pertains to the perioperative environment. Medications reviewed include gabapentinoids, acetaminophen, non-steroidal anti-inflammatory drugs, ketamine, intravenous lidocaine, dexmedetomidine, and glucocorticoids. The use of peripheral nerve blocks and neuraxial analgesia are also discussed.

Expert opinion: In appropriate cases, regional anesthetic interventions are extremely useful for postoperative analgesia, including peripheral nerve blocks and neuraxial analgesia and while newer postoperative analgesics have been postulated, the literature on such is presently controversial. Coordinated approaches to pain management are recommended to reduce the need for opioids and to improve patient satisfaction post-surgery.

KEYWORDS:

• Multimodal analgesia
• acute pain service
• opioid
• perioperative

Article highlights

• Multimodal opioid-sparing analgesia is an effective approach to postsurgical care

• Pharmacological non-opioid agents for pain control include the gabapentinoids, non-steroid anti-inflammatory drugs, magnesium, lidocaine, NMDA-antagonists, glucocorticoids, and alpha2-agonists.

• When appropriate, regional anesthesia interventions are extremely useful for postoperative analgesia, including peripheral nerve blocks and neuraxial analgesia

• Newer agents for postoperative analgesia include HTX-011, SABER-bupivacaine, and liposomal bupivacaine, although the literature is still controversial

• A coordinated approach to pain management, including an Acute Pain Service or Enhanced Recovery After Surgery pathway, may aid in reducing opioid requirements and improving patient satisfaction in the surgical population.

This box summarizes key points contained in the article.

Declaration of interest

RA Gabriel, MW Swisher, JF Sztain, TJ Furnish and ET Said have received funding and products for research purposes via from their institution from Myoscience and Epimed as well as from Infutronics, Ferrosan Medical and SPR Therapeutics. Meanwhile, BM Ilfeld has received research funding and products for research purposes via his institution from Myoscience, Epimed, Infutronics, Ferrosan Medical, SPR Therapeutics, Pacirca Pharmaceuticals and Heron Pharmaceuticals. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript has not been funded.