An update on the role of multimodal analgesia in perioperative pain management

Multimodal analgesia has become a foundational principle of acute perioperative pain management and enhanced recovery and involves the application of nonpharmacologic, pharmacologic, and/or interventional techniques. The overall goal of this approach is to apply a combination of different modalities that target discrete points along the pain pathway and thereby avoid the overreliance on opioids and associated side effects. Since our review in 2018, there have been significant developments that have prompted an updated review of multimodal analgesia. In this article, we identify and summarize important trends that influence the current approach to acute perioperative pain management as well as provide an updated clinical guide on multimodal analgesia with an emphasis on novel therapies. While a continued emphasis on multimodal opioid-sparing analgesia remains, additional evidence, newer regional techniques, and novel agents such as suzetrigine have emerged since our last review and have expanded options for perioperative pain management. In addition, special situations require specific recommendations, such as when designing a perioperative pain management plan for surgical patients who have opioid tolerance or live with opioid use disorder. These complex patients are at a higher risk for poor postoperative pain control and other adverse outcomes. This review includes suggested guidance on tailoring multimodal analgesia in this population with patient-specific therapies that can be added for appropriate indications and are supported by available evidence and guidelines.