Non-Opioid Perioperative Pain Strategies for the Clinician: A Narrative Review

Abstract

Alternative and non-opioid options for pain management are necessary in perioperative patient care. Opioids are no longer touted as cure-all medications, and furthermore, there have been tremendous advances in alternative therapies such as in interventional pain, physical therapy, exercise, and nutritional counseling that have proven benefits to combat pain. The center for disease control now strongly recommends the use of multimodal analgesia and multidisciplinary approaches based on the individual needs of patients: personalized medicine. In this manuscript, the specifics of non-opioid pharmacological and non-pharmacological analgesic approaches will be discussed as well as their possible indications and uses to reduce the need for excessive use of opioids for adequate pain control.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

“…The paradigm is not simply “opioid avoidance,” and requires balancing the risks of both over- and under-utilization of these high-risk agents. To this end, postoperative opioid minimization should be pursued only in the greater context of optimizing acute pain management, reducing adverse events, and preventing persistent postoperative pain through comprehensive multimodal analgesia [ 19 , 33 , 55 , 56 , 57 , 58 , 59 , 60 , 61 ]. Multimodal analgesia, or the use of multiple modalities of differing mechanisms of action, is key to decreasing surgical recovery times and complications, and so is also a fundamental component of the enhanced recovery paradigm promoted by the international Enhanced Recovery After Surgery (ERAS ® ) Society [ 19 , 24 , 62 , 63 , 64 , 65 ].…”

“…While evidence is insufficient to strongly recommend specific strategies, perioperative cognitive-behavioral therapies including guided imagery and music therapy are noninvasive and unlikely to cause harm. Their positive effects on reducing anxiety may provide downstream benefits to narcotic avoidance and analgesia, but further study is needed [ 15 , 55 , 156 , 157 , 158 , 159 , 160 ]. Massage and physiotherapy have contributed to improved pain control in other settings and are being explored for perioperative applications [ 55 ].…”

“…Their positive effects on reducing anxiety may provide downstream benefits to narcotic avoidance and analgesia, but further study is needed [ 15 , 55 , 156 , 157 , 158 , 159 , 160 ]. Massage and physiotherapy have contributed to improved pain control in other settings and are being explored for perioperative applications [ 55 ]. Preoperative virtual reality technology has also been successfully employed to reduce perioperative anxiety and pain [ 161 , 162 , 163 ].…”

“…Postoperative pain management should continue to incorporate multiple treatment modalities to maximize therapeutic benefits and minimize complications, including nonpharmacologic strategies ( Table 7 ) [ 15 , 55 ]. Physical modalities, including transcutaneous electrical nerve stimulation (TENS), acupuncture, massage, or cold therapy, alone or in combination with medications, may offer pain relief and reduce opioid use, though evidence is variable [ 15 , 55 , 158 , 160 , 347 , 350 , 378 ].…”

“…Postoperative pain management should continue to incorporate multiple treatment modalities to maximize therapeutic benefits and minimize complications, including nonpharmacologic strategies ( Table 7 ) [ 15 , 55 ]. Physical modalities, including transcutaneous electrical nerve stimulation (TENS), acupuncture, massage, or cold therapy, alone or in combination with medications, may offer pain relief and reduce opioid use, though evidence is variable [ 15 , 55 , 158 , 160 , 347 , 350 , 378 ]. Preliminary evidence also suggests cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), other mindfulness-based psychotherapy and music may reduce postoperative pain intensity and disability [ 15 , 79 , 379 , 380 , 381 ].…”