The role of non-opioid analgesic techniques in the management of pain after ambulatory surgery

As more extensive and painful surgical procedures (e.g., laparoscopic cholecystectomy, adrenalectomy, and nephrectomy, as well as prostatectomy, laminectomy, shoulder and knee reconstructions, and hysterectomy) are performed on an outpatient or short-stay basis, the use of multimodal perioperative analgesic regimens containing non-opioid analgesic therapies will probably assume an increasingly important role in facilitating the recovery process and improving patient satisfaction (3). Optimizing pain management is necessary to maximize the benefits of ambulatory surgery for both patients and health care providers. Additional outcome studies are needed to validate the beneficial effects of these newer therapeutic approaches with respect to important recovery variables (e.g., resumption of normal activities and return to work). Although many factors other than pain per se must be controlled to minimize postoperative morbidity and facilitate the recovery process after ambulatory surgery, pain remains a major concern of all patients undergoing surgical procedures (102). It is clear that the anesthetic technique can influence the analgesic requirement in the early postoperative period. Although opioid analgesics will continue to play an important role in the management of moderate to severe pain after surgery, the adjunctive use of nonopioid analgesics will probably assume a greater role in the future. Although opioid-free anesthesia may not yet be feasible for major intracavitary surgical procedures, it is becoming increasingly popular for superficial procedures in the ambulatory or office-based setting (103-105). In addition to the local anesthetics, NSAIDs, acetaminophen, and ketamine, nonopioid drugs such as adenosine, β-blockers, α2-agonists, and steroids have also been shown to be potentially useful adjuvants during or after surgery (82,106-112). Use of analgesic drug combinations with differing mechanisms of action may provide additive or even synergistic effects with respect to improving pain control and facilitating the recovery process. Finally, safer, simpler, and less costly analgesic drug delivery systems are needed to provide for more cost-effective pain relief in the postdischarge period after ambulatory surgery. In conclusion, "stress-free" anesthesia with minimal postoperative discomfort should be achievable for the majority of outpatients undergoing ambulatory surgical procedures, with the appropriate use of multimodal analgesic techniques. The aim of the analgesic technique should be not only to lower the pain scores, but more importantly to facilitate earlier mobilization and rehabilitation by reducing complications after discharge home. Recent evidence suggests that clinicians can more effectively prevent postoperative pain and improve the recovery profile after ambulatory surgery by using a combination of preemptive multimodal techniques involving both centrally and peripherally acting analgesic drugs, as well as nonpharmacologic therapies.