Although pain after surgery is expected, it must be appropriately managed, as poorly managed pain delays recovery, impairs wound healing, limits mobility, and increases the risk of developing chronic pain that can persist for months or even years1,2. For decades, opioid analgesia was the leading form of postoperative pain management. While these powerful drugs remain an important analgesic tool, solely relying on them is neither the safest nor the most effective approach. Multimodal analgesia has emerged as a better path forward, as it addresses pain with multiple approaches to limit the side effects caused by any individual approach.
In the 1990s, Danish physicians Henrik Kehlet and Jørgen Dahl observed that virtually all research on postoperative pain at the time focused on single-drug treatments1. Their core insight was that rather than using one medication at a high dose, which inevitably brings significant side effects, clinicians could combine several different medications and techniques, each targeting a different point along the body’s pain pathways. The result is better pain relief at lower doses of each individual agent, with a more manageable side effect profile overall.
Pain travels through the body in a series of stages. Noxious stimuli are first detected by nerve receptors in the tissues (transduction), then transmitted through nerves to the spinal cord, modulated along the way, and finally perceived in the brain2. Different medications interrupt different stages of this cascade. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and ketorolac reduce inflammation at the site of injury, and acetaminophen provides additional analgesia through central nervous system pathways. Local anesthetics block nerve conduction directly, while gabapentinoids calm abnormal electrical activity in pain-carrying nerves. Lastly, ketamine blocks NMDA receptors that amplify pain signals in the spinal cord.
The substantial amount of evidence supporting multimodal analgesia has become codified in major clinical guidelines. A landmark 2016 joint guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists reviewed thousands of studies and issued a strong recommendation that all surgical patients receive multimodal analgesia3. The guideline specifically recommends that unless there is a reason not to use them, patients should routinely receive acetaminophen and NSAIDs as foundational components of their pain plan, with regional anesthesia strongly encouraged for major procedures. Opioids remain available when needed but are explicitly positioned as adjuncts rather than defaults.
Beyond the pharmacological combinations, current thinking emphasizes that pain management cannot be purely about medication. Physical therapy, guided relaxation, transcutaneous electrical nerve stimulation, and patient education all contribute meaningfully to recovery2,3. A recent 2025 review highlighted that a significant barrier to better pain management is a persistent gap in medical education, as many surgeons and residents receive inadequate formal training in how to implement these strategies in practice2.
For the patient, understanding multimodal analgesia means knowing that one can and should expect more than a prescription for opioids after surgery. Before any procedure, it is reasonable for patients to ask their surgical and anesthesia teams what their pain management plan involves, whether a nerve block is appropriate for their operation, and how opioids will be used minimally and tapered as they recover. The ultimate goal of this approach is for the patient to safely and smoothly recover, with minimal side effects.
References
- Kehlet, H. & Dahl, J. B. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth. Analg. 77, 1048–1056 (1993). https://doi.org/10.1213/00000539-199311000-00030
- Lopez, B. M. et al. Postoperative multimodal pain management: a narrative review of current practices, clinical and educational gaps, and future directions. Front. Anesthesiol. 4, 1709252 (2025). https://doi.org/10.3389/fanes.2025.1709252
- Chou, R. et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J. Pain 17, 131–157 (2016). https://doi.org/10.1016/j.jpain.2015.12.008