Opioid sparing strategies for perioperative pain management other than regional anaesthesia: A narrative review

Abstract

Opioids play a crucial role in pain management in spite of causing increased hospital morbidity and related costs. It may also cause significant risks such as postoperative nausea and vomiting (PONV), sedation, sleep disturbances, urinary retention and respiratory depression (commonly referred to as opioid related adverse effects) in postoperative patients. In order to evade these opioid related side effects and also improve pain management, multimodal analgesia i.e., combination of different analgesics, was introduced more than a decade ago. Both pharmacological and non-pharmacological techniques are available as opioid sparing analgesia. Research from around the world have proved pharmacological techniques ranging from acetaminophen, NSAIDs (non-steroidal anti-inflammatory drugs), N-methyl-D-aspartate receptor antagonists (NDMA), alpha-2 agonists, anticonvulsants such as gamma aminobutyric acid analogues, beta-blockers, capsaicin, lignocaine infusion to glucocorticoids to be effective. On the other hand, non-pharmacological methods include techniques such as cognitive behavioral therapy, transcutaneous electrical nerve stimulation (TENS), electroanalgesia, acupuncture and hypnosis. However, research regarding the effect of these non-pharmacological techniques on pain management is still needed.

Re: “Effect of Multimodal Preemptive Analgesia of Flurbiprofen Axetil, Nalbuphine, and Retrobulbar Block on Postoperative Pain and Enhanced Recovery in Patients Undergoing Oculoplastic Day Surgery: A Prospective, Randomized, Double-Blinded Study”

“…When there is herniated nasal and central fat with significant inferior orbital rim hollowing or nasojugal depression, the decision to reposition the entire or partial nasal and central fat pads with excision of the 2 temporal fat pads is also relatively easy to make since in these cases, fat excision alone will only accentuate the hollowing. 3,4 The dilemma is when there is herniated lower eyelid fat with minimal inferior orbital rim hollowing or when patients note lower eyelid "circles." In these cases, the decision to excise or reposition fat is more difficult to make.…”

“…Furthermore, it is generally recommended that the administration of basic analgesics should be started before or during the operation and regularly carried out after surgery. 4 As most patients undergoing ophthalmic operations experience pain for a median of 3 days (range 3–9 days), regular basic analgesics are often prescribed for 3 days after surgery. The available evidence indicates that the effervescent formula of paracetamol is very effective for pain control after ophthalmic surgery when it is used in sufficient dosages and frequent intervals.…”

“…Furthermore, average NRS scores over the first 24 h in 3 groups were less than 3, indicating that adequate pain control is achieved in most of the patients. 4 Most important, this study did not evaluate patient satisfaction with postoperative pain control. In these cases, it is very difficult for the readers to determine whether the statistical differences between groups F and N in postoperative pain outcomes reported by this study are clinically significant.Second, oral paracetamol was administered as a rescue analgesic when an NRS score was more than 4, indicating moderate to severe pain during the postoperative period.…”

Letter to the Editor

“…Furthermore, oral administration of acetaminophen, celecoxib, and gabapentin immediately before surgery also was part of the ERAS protocol. In fact, acetaminophen, nonsteroidal anti-inflammatory drugs, and gabapentin are the important component of an opioid-sparing multimodal analgesia recommended in the current ERAS practices, and they can greatly decrease opioid consumption for postoperative pain control by different mechanisms 3,4 . In this case, we argue that the between-group difference of opioid consumption in the PACU should not be completely attributable to different postoperative analgesic efficacies of 2 regional block techniques.…”