Post-Surgical Pain Management: Multimodal Strategies to Reduce Opioid Use

Why post-surgical pain doesn’t have to mean opioids

After surgery, pain is normal. But needing strong opioids like morphine or oxycodone? That’s not inevitable. In fact, it’s becoming outdated. Hospitals across the U.S. and U.K. are shifting away from relying on opioids alone to manage pain after operations. Instead, they’re using multimodal analgesia-a smart mix of medications, nerve blocks, and non-drug techniques-to control pain better and use far fewer opioids. The goal isn’t just to make patients comfortable-it’s to prevent addiction, reduce side effects, and get people home faster.

What is multimodal analgesia (MMA)?

Multimodal analgesia means using more than one type of painkiller at the same time, each working in a different way. Instead of giving a high dose of one drug-like an opioid-doctors combine lower doses of several non-opioid drugs. This creates a stronger overall effect without the same risks. Think of it like a team: acetaminophen handles general pain, gabapentin calms nerve signals, NSAIDs reduce swelling, and regional nerve blocks numb the surgical area. Together, they do more than any single drug could.

This approach isn’t new, but it’s now the standard. In 2021, 14 major medical groups-including the American Society of Anesthesiologists-came together to agree on seven core principles for post-surgical pain control. One of the biggest takeaways? Opioids should be the last resort, not the first.

How much can you really cut opioid use?

The numbers speak for themselves. Studies show that when hospitals use full multimodal protocols, patients use 32% to 57% fewer opioids after surgery. In spine surgery cases at Rush University Medical Center, average opioid use dropped from 45.2 morphine milligram equivalents (MME) per day to just 18.7 MME per day-a 61% reduction. Patients still reported pain levels below 4 out of 10 on the pain scale. That’s effective relief with far less risk.

For joint replacements, opioid use drops by 50-60%. Even for smaller procedures like knee arthroscopies, reductions of 30-40% are common. And it’s not just about pills. Patients on MMA spend less time in the hospital. At McGovern Medical School, average stays dropped from 7.2 days to 5.4 days after implementing their protocol. Same-day discharge rates jumped from 12% to 37% for eligible surgeries.

What drugs are actually used?

Here’s what a typical MMA plan looks like, broken down by timing:

• Before surgery: Patients get acetaminophen (1000 mg), gabapentin (300-600 mg), and celecoxib (400 mg). Starting these early helps stop pain signals before they even begin.
• During surgery: Anesthesiologists may add ketamine (a low-dose IV infusion), lidocaine (an IV nerve blocker), or dexmedetomidine (a calming agent that reduces opioid needs).
• After surgery: Scheduled doses continue: acetaminophen every 6 hours, gabapentin three times daily, and NSAIDs like naproxen or celecoxib twice daily. Opioids? Only for breakthrough pain-and even then, in tiny doses like 1-2 mg of morphine IV, given only when needed.

For patients who want or need to avoid opioids entirely-like those with past addiction or chronic pain-protocols include longer infusions of ketamine or lidocaine, or even continuous numbing through catheters placed near the surgical site.

Who benefits most?

MMA works best for surgeries with predictable, localized pain: joint replacements, spine procedures, abdominal operations, and major trauma cases. But it’s not one-size-fits-all. A 70-year-old with kidney issues can’t take naproxen. Someone with liver disease needs lower doses of gabapentin. A patient who’s been on opioids for years might need higher doses of non-opioid drugs to even start feeling relief.

That’s why every plan starts with a pre-op check: medical history, kidney and liver function, mental health, and past opioid use. The American Society of Anesthesiologists says this evaluation isn’t optional-it’s essential. One size doesn’t work for everyone. The best MMA plan is the one tailored to the patient, not the procedure.

It’s not just pills-it’s teamwork

Getting MMA right takes more than writing a prescription. It needs a whole team: anesthesiologists, pharmacists, nurses, surgeons, and pain specialists. Coordination starts before the patient even enters the operating room. Pre-op meds must be timed correctly. Pain scores must be tracked every two hours for the first 24 hours. Nurses need to know when to give a non-opioid instead of reaching for morphine. Pharmacists must check for drug interactions-like avoiding NSAIDs in patients with low kidney function.

At McGovern Medical School, they built their protocol into the hospital’s electronic ordering system so it’s automatic. No one has to remember to order it-it’s just there. That’s what makes it stick. Without systems like this, even the best plan fails.

What about side effects?

Opioids cause nausea, vomiting, drowsiness, constipation, and breathing problems. MMA reduces all of these. One study found a 28% drop in postoperative nausea and vomiting compared to opioid-only care. Patients are more alert, can eat sooner, and get out of bed faster-all key parts of faster recovery.

Non-opioid drugs have their own risks. Gabapentin can cause dizziness or drowsiness, especially in older adults. NSAIDs like naproxen can harm kidneys or cause stomach bleeding, so they’re avoided in people with kidney disease or ulcers. That’s why dosing is adjusted. For example, if a patient’s kidney function is below 30 mL/min, gabapentin is cut to 200 mg once a day, and naproxen is stopped entirely.

What’s next for pain management?

The future of MMA is personalization and continuity. More hospitals are starting to prescribe gabapentinoids for 5 to 10 days after discharge to help prevent pain from turning chronic. Continuous nerve blocks with local anesthetics are becoming common for high-risk patients. And there’s growing interest in non-drug tools-like cold therapy, guided breathing, and distraction techniques-that can be used alongside meds.

By 2025, experts predict 85% of major surgeries will use formal MMA protocols. That’s up from about 60% in 2022. The goal isn’t just to manage pain-it’s to change how we think about it. Pain after surgery doesn’t have to mean dependence. With the right mix of science, teamwork, and patient focus, recovery can be safer, faster, and opioid-free.

What if you’re already on opioids?

If you’re taking opioids regularly for chronic pain, stopping them suddenly after surgery can make things worse. The American Academy of Pain Medicine says: don’t stop your regular meds. Instead, add multimodal options on top. Keep your usual dose, and layer in acetaminophen, gabapentin, or nerve blocks to reduce the extra opioids you need after surgery. It’s not about cutting your pain meds-it’s about adding smarter tools so you don’t need more.