Advances in the application of opioid-free anesthesia and multimodal analgesia in perioperative pain management: a narrative review

Perioperative analgesia constitutes an integral component of anesthetic practice and enhanced recovery after surgery (ERAS). Opioids, by virtue of their potent analgesic efficacy, have long served as the cornerstone of perioperative pain management. Nevertheless, opioid-related adverse effects—including respiratory depression, nausea and vomiting, opioid-induced hyperalgesia, postoperative ileus, and immunosuppression—substantially compromise the quality of postoperative recovery, and the escalating global opioid abuse crisis has prompted the anesthesiology community to reappraise perioperative analgesic strategies. Opioid-free anesthesia (OFA), as an innovative anesthetic paradigm grounded in the concept of multimodal analgesia, seeks to entirely avoid intraoperative opioid administration through the combined use of multiple non-opioid agents [including α 2 -adrenergic receptor agonists, N-methyl-D-aspartate (NMDA) receptor antagonists, nonsteroidal anti-inflammatory drugs, and lidocaine] together with regional anesthetic techniques, thereby eliminating opioid-related adverse effects at their source. In recent years, with the progressive implementation of ERAS principles and the continued development of non-opioid analgesic agents, the feasibility and clinical value of OFA have attracted considerable attention. This review synthesizes the theoretical basis, commonly employed agents and regimens, clinical research progress, and controversies and limitations of OFA in adult and pediatric perioperative analgesia. Given the distinctive pharmacokinetic profiles and perioperative risk profiles of pediatric patients, particular emphasis is placed on the implementation strategies and clinical considerations of OFA in children, together with a perspective on future directions, with the aim of providing a reference for the optimization of perioperative pain management.