Current update on multimodal analgesia and nonopiate surgical pain management

Biochemical strategies for opioid-sparing pain management in the operating room

The opioid epidemic has highlighted the increasing need for alternative pain relievers in surgical settings. This review explores non-opioid approaches for managing pain in the ever-changing operating room. The review examines the molecular basis of pain perception, with a focus on receptor-targeted treatments that offer effectiveness without the risks associated with opioids. Despite the demonstrated benefits and improved side effect profiles, our literature analysis reveals the challenges that hinder the integration of innovative pain relievers. We explore the potential of neuroimmune modulators, peptide disruptors, and new neurotransmitter analogs in the quest for effective pain relief, paving the way for a future of anesthesia without opioids.

Rhomboid Intercostal and Subserratus Plane Block for Acute Pain Management after Abdominal Surgeries: A Narrative Review

PURPOSE OF REVIEW

The rhomboid intercostal and subserratus plane (RISS) block is an effective, safer alternative for managing postoperative acute pain following abdominal surgeries. The RISS block offers several advantages over traditional approaches, including reduced incidence of puncture-related complications, lower rates of systemic opioid consumption, and more consistent analgesic coverage of lower thoracic dermatomes.

RECENT FINDINGS

Despite a favorable safety profile, the RISS block carries potential risks, such as pneumothorax and local anesthetic systemic toxicity, particularly when long-acting anesthetics such as bupivacaine or ropivacaine are used. Careful administration with ultrasound guidance minimizes these risks, enhancing patient safety. Compared to epidural and paravertebral blocks, RISS is associated with fewer instances of nerve damage, hemodynamic instability, and bleeding. Research suggests that RISS not only improves postoperative pain scores, but also extends duration of analgesic effect, reducing total opioid use by nearly 40%.

CONCLUSION

Future directions include clinical trials to validate efficacy across diverse patient populations, comparative studies with other regional blocks, and evaluations of long-term outcomes. Expanding our understanding of RISS block application may help advance multimodal pain management protocols, underscoring potential to improve recovery, reduce opioid dependency, and elevate patient quality of life in postoperative settings.

"Opioid free colorectal surgery: Outcomes of successful non-opiate colorectal surgery in a rural community teaching hospital"

BACKGROUND

Opiates present challenges due to side effects, including prolonged hospitalization and delayed bowel function. Enhanced Recovery After Surgery (ERAS) protocols advocate for multimodal pain management, yet few studies explore entirely non-opiate approaches.

METHODS

134 elective ERAS colorectal surgery patients were reviewed from January 2019 to June 2020 ​at a single institution, with surgery performed by a single surgeon. Endpoints were pain scores, length of stay (LOS), and mortality.

RESULTS

Forty patients were included in the non-opiate cohort. Mann Whitney-U test found that postoperatively, non-opiate patients spent significantly less time in moderate or severe pain (p ​< ​.001). There was no significant difference between study groups (non-opiate and opiate) for the no or mild pain categories, LOS, or mortality. Risk factors for opiate use were younger age and prior opiate use. Gender, ASA class, stoma creation, malignancy, and surgical approach were not associated with increased opiates.

CONCLUSION

Non-opiate approaches in colorectal surgery are feasible and comparable to opiate regimens in our patient cohort.

Perioperative pain optimization in the age of the opioid epidemic

PURPOSE OF REVIEW

The opioid epidemic remains a constant and increasing threat to our society with overdoses and overdose deaths rising significantly during the COVID-19 pandemic. Growing evidence suggests a link between perioperative opioid use, postoperative opioid prescribing, and the development of opioid use disorder (OUD). As a result, strategies to better optimize pain management during the perioperative period are urgently needed. The purpose of this review is to summarize the most recent multimodal analgesia (MMA) recommendations, summarize evidence for efficacy surrounding the increased utilization of Enhanced Recovery After Surgery (ERAS) protocols, and discuss the implications for rising use of buprenorphine for OUD patients who present for surgery. In addition, this review will explore opportunities to expand our treatment of complex patients via transitional pain services.

RECENT FINDINGS

There is ample evidence to support the benefits of MMA. However, optimal drug combinations remain understudied, presenting a target area for future research. ERAS protocols provide a more systematic and targeted approach for implementing MMA. ERAS protocols also allow for a more comprehensive approach to perioperative pain management by necessitating the involvement of surgical specialists. Increasingly, OUD patients taking buprenorphine are presenting for surgery. Recent guidance from a multisociety OUD working group recommends that buprenorphine not be routinely discontinued or tapered perioperatively. Lastly, there is emerging evidence to justify the use of transitional pain services for more comprehensive treatment of complex patients, like those with chronic pain, preoperative opioid tolerance, or substance use disorder.

SUMMARY

Perioperative physicians must be aware of the impact of the opioid epidemic and explore methods like MMA techniques, ERAS protocols, and transitional pain services to improve the perioperative pain experience and decrease the risks of opioid-related harm.