Optimizing Perioperative Use of Opioids: A Multimodal Approach

Abstract

Purpose of review: The main purpose of this article is to review recent literature regarding multimodal analgesia medications, citing their recommended doses, efficacy, and side effects. The second part of this report will provide a description of drugs in different stages of development which have novel mechanisms with less side effects such as tolerance and addiction.

Recent findings: Multimodal analgesia is a technique that facilitates perioperative pain management by employing two or more systemic analgesics along with regional anesthesia, when possible. Even though opioids and non-opioid analgesics remain the most common medication used for acute pain management after surgery, they have many undesirable side effects including the potential for misuse. Newer analgesics including peripheral acting opioids, nitric oxide inhibitors, calcitonin gene-related peptide receptor antagonists, interleukin-6 receptor antagonists and gene therapy are under intensive investigation.

Summary: A patient's first exposure to opioids is often in the perioperative setting, a vulnerable time when multimodal therapy can play a large role in decreasing opioid exposure. Additionally, the current shift towards faster recovery times, fewer post-operative complications and improved cost-effectiveness during the perioperative period has made multimodal analgesia a central pillar of Enhanced Recovery After Surgery (ERAS) protocols.

Keywords: Analgesic; multimodal analgesia; opioids; surgery.

Figure.. Mechanism of action of novel analgesic

The figure illustrates the different mechanisms of action of novel analgesics. While some of them have shown efficacy in animal models, none of them has been introduce for routine clinical postoperative pain management. Transcription factor decoy therapies have been tested in phase II clinical trials.