Postoperative Pain Management: 5 Things to Know

Medscape

7 days ago

There has been significant evolution in postoperative pain management in recent years, with an increasing recognition of the variability in patient responses. This variability may limit the effectiveness of standardized protocols and contribute to both undertreatment and overtreatment. Although opioids remain a cornerstone for moderate-to-severe postoperative pain, concerns about adverse effects, prolonged use, and opioid use disorder (OUD) have intensified the push toward individualized, multimodal approaches.
Biologic and psychosocial variables such as central sensitization, catastrophizing behavior, and lifestyle factors also can influence outcomes and increase the risk for chronic postsurgical pain. Advances in pharmacology and drug delivery technologies, including long-acting local anesthetics and novel nonopioid agents, are helping address these challenges. Nonpharmacologic modalities such as cognitive-behavioral therapy (CBT) and patient education are also gaining traction as adjuncts in comprehensive care.
As clinicians seek to improve outcomes and reduce harm, the focus is shifting from reactionary prescribing to proactive, patient-tailored strategies.
Here are five things to know about postoperative pain management:
1. Standardized pain management does not work for everyone.
There is growing recognition that pain sensitivity and response to therapy exist along a spectrum, rather than fitting binary classifications of 'tolerant' or 'naive.' Therefore, a one-size-fits-all approach is insufficient for effective postoperative pain management. Research emphasizes the need for patient-centric strategies that consider prior experiences, psychological comorbidities (eg, anxiety, depression), substance use history, and lifestyle behaviors such as alcohol or tobacco use. These factors can significantly influence pain perception, analgesic efficacy, and complication risk.
Individualized care plans that incorporate shared decision-making improve patient satisfaction and reduce opioid exposure. For example, patients who exhibit high preoperative anxiety or pain-catastrophizing are more likely to experience severe postoperative pain and complications. Tailoring interventions — such as incorporating CBT or adjusting pharmacologic regimens — can improve outcomes.
2. Continue buprenorphine during surgery for patients with OUD.
Current evidence and expert consensus strongly recommend continuing buprenorphine during the perioperative period for patients with OUD. Discontinuing buprenorphine abruptly before surgery can lead to significant complications, including opioid withdrawal, uncontrolled pain, and increased risk for relapse, especially in individuals with a history of substance use. Withdrawal symptoms not only hinder recovery but may also prompt patients to seek illicit opioids, undermining the stability achieved through treatment.
The American Society of Regional Anesthesia and Pain Medicine Substance Use Disorder Multi‐Society Working Group recommends continuing buprenorphine perioperatively to reduce the risk for OUD recurrence and overdose and initiating it in untreated patients with acute pain. Historically, practices varied widely; however, growing evidence indicates that continued use of buprenorphine improves pain control, reduces opioid requirements, decreases inpatient pain consultations, and lowers the risk for OUD recurrence . Recent guidelines increasingly advocate maintaining the home dose perioperatively, with potential dose adjustments for major surgeries. To ensure adequate pain relief, clinicians often add multimodal strategies such as regional anesthesia, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and adjuncts such as ketamine or dexmedetomidine. Important to note: Discharge plans should include communication with the patient's buprenorphine prescriber , a taper plan for any additional opioids, and strategies to minimize relapse risk.
A multidisciplinary approach is essential. Surgeons, anesthesiologists, and addiction medicine providers must collaborate early in the surgical planning process to tailor pain management to the patient's needs. Recent publications emphasize the importance of this coordinated care model, which aligns with broader efforts to reduce opioid-related harm and support long-term recovery in individuals with OUD.
3. Virtual reality, CBT, and other nonpharmacologic modalities can meaningfully reduce postoperative pain and opioid use.
Evidence increasingly supports the integration of nonpharmacologic modalities into perioperative pain care. Virtual reality (VR), CBT, and mindfulness-based interventions have been shown to reduce pain scores, opioid consumption, and anxiety in pediatric and adult surgical populations. VR has been especially promising in managing procedural pain, distracting patients from acute discomfort, and enhancing engagement in rehabilitation. CBT can modulate central pain processing by addressing maladaptive thought patterns such as catastrophizing. These approaches are often used adjunctively, enhancing the effects of pharmacologic treatments and reducing reliance on opioids.
4. New drug delivery systems and nonopioid agents represent key advancements in postoperative pain control.
The landscape of postoperative pain management is undergoing a significant transformation, driven by advances in pharmacology, drug delivery systems, and clinical protocols that prioritize opioid-sparing strategies. In response to growing concerns about opioid-related adverse effects and the risk for long-term dependence, clinicians are increasingly embracing multimodal analgesia approaches that combine agents with complementary mechanisms of action to optimize pain control while minimizing harm.
Nonopioid agents are at the core of this shift. Medications such as intravenous acetaminophen, NSAIDs, gabapentinoids, ketamine, and dexmedetomidine have become foundational components in contemporary postoperative pain protocols.
These agents target different pain pathways — peripheral inflammation, central sensitization, N-methyl-D-aspartate receptor modulation, and alpha-2 adrenergic receptor activation — providing synergistic analgesia without the sedation, respiratory depression, or tolerance associated with opioids. For example, low-dose ketamine infusions have demonstrated efficacy in reducing acute postoperative pain and opioid requirements, particularly in opioid-tolerant patients or those with chronic pain conditions.
Recently, the US Food and Drug Administration granted approval to a first-in-class nonopioid analgesic to treat moderate-to-severe acute pain in adults. The agent, suzetrigine, targets a pain-signaling pathway involving sodium channels in the peripheral nervous system.
Also important are innovations in how analgesics are delivered. Long-acting local anesthetics, such as liposomal bupivacaine or polymer-based sustained-release formulations, allow for extended nerve blockade or wound infiltration, offering significant pain relief for up to 72 hours postoperatively. These formulations reduce the need for systemic medications and enhance patient mobility, which is a cornerstone of enhanced-recovery-after-surgery (ERAS) protocols.
Emerging drug delivery systems are also transforming postoperative care. Evolving technology focused on transdermal patches, subcutaneous implants, and iontophoretic devices enables continuous or patient-controlled analgesia with improved precision and fewer adverse effects. Recently launched or in-development devices aim to integrate real-time monitoring and adaptive dosing algorithms to personalize analgesia and prevent overmedication.
Together, these pharmacologic and technological advancements are ushering in a new era of postoperative pain management that prioritizes individualized care, safety, and functional recovery. The overarching goal is not merely to control pain but to do so in a way that accelerates healing, preserves patient autonomy, and mitigates the risks associated with opioid use. As new agents and delivery platforms continue to emerge, clinicians must remain informed and adaptable, integrating these tools thoughtfully into evidence-based practice.
5. Preoperative anxiety and preexisting pain are predictive of worse postoperative pain outcomes.
Numerous studies confirm that patients with chronic pain, preoperative anxiety, or depressive symptoms are at higher risk for severe postoperative pain and prolonged opioid use. Central sensitization phenomena, such as elevated temporal summation of pain and reduced pressure thresholds, are also predictive. Psychological factors such as catastrophizing can amplify pain perception and interfere with recovery. Preoperative screening and interventions, including patient education and behavioral therapy, have been shown to mitigate these effects and improve pain control.
Multidisciplinary teams are increasingly encouraged to assess and address perioperative risks early in the surgical planning process as part of a broader shift toward personalized, patient-centered care. This proactive approach brings together surgeons, anesthesiologists, nurses, pharmacists, physical therapists, and pain management specialists to collaboratively evaluate each patient's unique risk factors — including medical history, medication use, psychological status, and functional baseline — before surgery occurs. Early engagement allows the team to identify potential complications, such as adverse drug reactions, postoperative delirium, or prolonged opioid dependence, and implement tailored strategies to mitigate them.