Pain Management Strategies

Multimodal Analgesia

The opioid epidemic is a major public health crisis in the United States, costing the healthcare system over $1 trillion since 2001 and projected to exceed another $500 billion over the next three years.1 Addressing new persistent opioid use following surgical care is of great import and procedures are considered a gateway to opioid prescriptions.2 It is increasingly recognized that non-opioid analgesia is as effective as some opioid analgesia and that multimodal analgesia is better than exclusive opioid analgesia.   

Undertreatment of pain garnered national attention as an indicator of poor surgical quality and many reports cited physician insensitivity to pain and disparities in pain management related to gender, age and race.3 Ability to participate in and successfully complete rehabilitation and return to the community can be hampered by inadequate pain control.4–6

Multimodal analgesia is readily available, and the evidence is strong to support its efficacy. Surgeons and anesthesiologists should use this effective approach for patients both using and not using the ERAS pathway to reduce opioid consumption.7 A multimodal analgesic regimen can be designed such that the physiologic and pharmacologic benefits are maximized and the adverse effects are minimized to facilitate the patient’s recovery and return to baseline function.7 Please see Table 17 for a list of these benefits. In fact, hospital interventions can change the prescribing culture and increase the use of opioid-sparing medications.8

  • Multimodal analgesia focuses on opioid-sparing medication to avoid the harmful side effects of opioids, both short and long-term 
  • Multimodal analgesia is safe, and can be offered in different routes and doses

Enhanced Recovery After Surgery (ERAS) Pathways

The overarching focus of an Enhanced Recovery After Surgery (ERAS) program is to take a collaborative team approach to achieve an optimal preoperative condition before the date of surgery while minimizing disruption of the normal physiologic state through the remainder of the perioperative timeframe. Each surgical service meets on a regular basis with all team members who participate in the care of the patient to create a pathway from preoperative, intraoperative, and postoperative, that utilizes best practices from each stakeholder’s specialty.  

Specific to pain management, there is much reliance on utilization of multimodal analgesics such as gabapentin, acetaminophen, NSAIDs and regional anesthesia as examples with the goal to minimize opioid-related side effects.

Patient-Controlled Analgesia (PCA)


  • PCA uses an infusion pump to deliver a pre-programmed dose of an opioid medication when a demand button is pushed. PCA modes of delivery include demand dosing and demand dosing plus continuous basal infusion.
  • The minimal effective analgesic concentration (MEAC) is the lowest plasma opioid concentration at which pain relief can be achieved. PCA can effectively maintain the plasma MEAC, avoiding peaks and troughs that can be associated with side effects and periods of uncontrolled pain.1