Recent advances and practical strategies in opioid-free multimodal analgesia for surgical patients: a narrative review

Purpose: This review aims to provide an evidence-based overview of opioid-free analgesia (OFA) as an emerging strategy for perioperative pain management. Growing concerns regarding opioid-related adverse events, delayed recovery, and persistent postoperative opioid use have prompted a paradigm shift away from opioid-centered analgesia, transitioning first to opioid-sparing strategies and now toward the concept of opioid-free approaches. Drawing on recent meta-analyses and scoping reviews, this article critically evaluates the current strength of evidence supporting OFA and discusses key considerations for its implementation in clinical practice.Current Concepts: OFA combines non-opioid analgesic agents—including dexmedetomidine, ketamine, lidocaine, magnesium, acetaminophen, and nonsteroidal anti-inflammatory drugs—administered with or without regional analgesic techniques. Intraoperative OFA protocols have been shown to reduce the incidence of postoperative nausea and vomiting and to modestly alleviate early postoperative pain, without impairing hemodynamic stability or overall safety. After discharge, OFA provides analgesic efficacy comparable to opioid-based regimens while reducing the occurrence of opioid-related adverse effects. However, the magnitude of these benefits remains relatively modest, and existing clinical evidence is insufficient to support the routine adoption of OFA. Moreover, evidence supporting its effectiveness in the immediate postoperative period remains limited.Discussion and conclusion: OFA represents a promising yet still developing approach in perioperative care. The complete elimination of opioids should not supersede the fundamental goal of ensuring adequate analgesia and promoting functional recovery. Successful implementation requires individualized, procedure-specific protocols that integrate multimodal strategies and allow judicious opioid rescue when necessary. Additional high-quality randomized controlled trials are required to establish its clinical efficacy, cost-effectiveness, and safety.