Opioid-Sparing Multimodal Analgesia: A Twelve-Month Cohort Across Four Analgesic Approaches in Three Hundred and Eighty-Six Surgical Patients Pain Control, Opioid Consumption, Adverse Events, and Recovery Outcomes by Analgesic Strategy

Abstract

Opioid stewardship in perioperative care has emerged as a central priority given concerns about both acute adverse effects (nausea, sedation, respiratory depression, ileus, pruritus) and longer-term consequences (persistent postoperative opioid use, transition to chronic opioid use, and contribution to broader opioid crisis dynamics). Multimodal analgesic approaches combining non-opioid pharmacological agents (acetaminophen, NSAIDs, gabapentinoids, ketamine, alpha-2 agonists) with regional anaesthesia where appropriate are recommended by enhanced recovery after surgery (ERAS) protocols and pain management societies. We undertook a 12-month prospective cohort study of 386 surgical patients across five surgery categories comparing four analgesic approaches: multimodal with regional anaesthesia (n=178), multimodal without regional (n=108), opioid-predominant with adjuncts (n=64), and opioid-only (n=36). Multimodal-plus-regional patients had substantially lower pain scores (mean 2.6 vs 7.2 at 24h for opioid-only), lower 72h opioid consumption (mean 28 vs 168 MME), shorter length of stay (3.4 vs 6.8 days), and fewer opioid-related adverse events. Strongest predictors of poor outcomes included opioid-only approach, pre-existing chronic pain, prior opioid use, anxiety, and pain catastrophising. Multimodal regimens, regional anaesthesia, and preoperative education were strongly protective.

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