4 days ago
Q&A: Postoperative Pain Management
Dr Scott Pritzlaff
Dr Scott Pritzlaff, an anesthesiologist and pain medicine specialist at UC Davis Health, discusses contemporary pain management strategies across the surgical spectrum. In this interview, he shares how practices have evolved in response to the opioid crisis, highlights innovations such as peripheral nerve stimulation and multimodal analgesia, and reflects on the current challenges in fellowship training and health equity in pain care.
How has the opioid crisis changed surgical pain management?
I think everyone has adapted in some way. Back in 2011 when I was an anesthesia resident, there was more of a one-size-fits-all approach — mainly focused on prescribing postoperative opioids. But things have shifted significantly. There's much more emphasis now on upfront risk stratification.[1] Patients who are on chronic opioids, or who have psychological risk factors such as anxiety, depression, or catastrophizing, are much more likely to have poor outcomes after surgery.[1,2] These risk factors are modifiable, and early identification has become a key priority in optimizing surgical outcomes.
How have conversations around pain expectations changed with patients?
There's a lot more discussion now about function rather than just the pain score. The 'pain as the fifth vital sign' era pushed us to treat numbers, but that doesn't reflect how a patient is actually doing. Today, we're talking more about their ability to mobilize and return to activity. That's also driven innovation. For instance, instead of traditional femoral nerve blocks, we're using more targeted peripheral nerve blocks and catheters that preserve mobility.[3,4] These are key components of enhanced recovery after surgery (ERAS) protocols,[5] which have helped transform care for procedures like joint replacements — many of which are now same-day surgeries.
How do you manage patient expectations about pain control?
It really depends on how the conversation is framed. I make it clear that the goal is to manage symptoms — not to eliminate pain entirely. Words like 'cure' or '100% relief' can set unrealistic expectations. But I also let patients know we now have tools we didn't have 15 or 20 years ago. One example is peripheral nerve stimulation, which involves placing a small wire next to a nerve and modulating the nerve's signals using electricity — somewhat like a transcutaneous electrical nerve stimulation (TENS) unit, but implanted.[3,4] These percutaneous systems are fairly new, only widely available since 2016, and offer a promising option for patients with persistent pain after surgery.
In your view, what was the turning point in opioid prescribing?
A pivotal shift occurred in 2016, when both the Centers for Disease Control and Prevention (CDC) and the US Surgeon General issued strong national guidance in response to the escalating opioid crisis. The CDC released prescribing guidelines that emphasized caution with opioid use, introduced preliminary morphine milligram equivalent thresholds, and advocated for nonopioid therapies as first-line treatments for chronic pain.[6] Simultaneously, the Surgeon General circulated an open letter to healthcare professionals, urging more responsible prescribing practices and highlighting the growing toll of opioid-related harm.[7] But the unintended consequence was a rise in illicit use, especially with fentanyl. So, while prescribing went down, opioid-related deaths continued to climb. Some argue the response was too abrupt, particularly from primary care providers, and we're still dealing with those consequences.
Is there evidence that these perioperative interventions are effective?
Yes. Studies have shown that chronic opioid use before surgery predicts higher opioid needs afterward.[1,2] Ketamine, for example, has been shown to modestly reduce perioperative opioid use.[8] It's used in the emergency department setting — my daughter had it when she broke her arm. It's effective, and the patient remains breathing on their own but is unaware. Similarly, ERAS protocols[5] and peripheral nerve stimulation[3,4] have shown promise in reducing opioid consumption, which in turn lowers the risk for substance use disorder.
Where do gabapentinoids fit into the picture?
Gabapentin and pregabalin have been widely used as part of ERAS protocols. A decade ago, we were prescribing them for many pain conditions. But the evidence has been mixed, and, in older patients they can cause dizziness, confusion, and falls.[5] They still have a role, especially in managing neuropathic pain, but they're not the wonder drugs we once thought they were. There's also some abuse potential, particularly with pregabalin, which is a Drug Enforcement Administration schedule V medication.
Are you using digital tools or wearables to monitor pain after surgery?
Yes, though it's primarily in the chronic pain space where we're seeing the most adoption. For example, newer spinal cord stimulator systems can now transmit data directly to the patient's smartphone, allowing real-time tracking and personalized adjustments. Sleep metrics are also gaining attention, because disrupted sleep is closely tied to higher pain sensitivity and worse outcomes.[9] Some newer wearable TENS units integrate artificial intelligence to adapt stimulation patterns based on user feedback, all managed through connected apps. That said, many of these technologies are still paid out of pocket, which limits accessibility and makes broad integration into routine postoperative care more challenging.[10]
What is your experience with suzetrigine?
I haven't used suzetrigine yet, but I know hospitals are starting to stock it. It's approved for acute pain and was studied in soft tissue (abdominoplasty) and hard tissue (bunionectomy) models. It's a highly selective Nav1.8 sodium-channel blocker, which acts peripherally with minimal central nervous system or cardiac side effects.[11] Patients with chronic pain are already asking about it. It's definitely a medication to watch.
How do you manage surgical pain in patients with a history of substance use disorder?
That's a nuanced challenge. Many of these patients are on buprenorphine, which binds tightly to opioid receptors but doesn't fully activate them. That makes it difficult to manage pain with traditional opioids — they just don't work as well unless given in high doses. Some surgeons are uncomfortable with continuing buprenorphine through the perioperative period, but the trend is shifting. At my hospital, we have a dedicated inpatient pain service that helps manage these cases. Stopping buprenorphine carries a high risk for relapse, so we often continue it, or use it acutely alongside other treatments.[12]
How is pain fellowship training evolving to keep pace with the field?
It's a big issue. Pain medicine fellowships have been 1 year long since the 1990s, when the field was focused on medications and simple procedures such as epidurals. But the landscape has changed drastically — now we're doing neuromodulation, minimally invasive spine interventions, and managing complex pharmacology like buprenorphine.[13,14] There is an increasing discussion about standardizing training, extending fellowship to 2 years, or even turning it into a standalone residency.[15] Anesthesiologists are applying less owing to high job demand, and more physiatrists are entering the field. That's another driver for standardization.
Are there any tools or technologies you think are underutilized in pain management?
Virtual reality has real promise.[16] We've used it for pain procedures and in pediatric populations to reduce anxiety. It's also being explored in chronic pain settings as a nonpharmacologic intervention.[17] I think we'll see wider adoption as the hardware improves and costs come down.
We also recently studied radiofrequency ablation for chronic knee osteoarthritis.[18,19] There's growing interest in using it preoperatively — say, a month before joint replacement — to reduce postoperative pain and opioid use. Peripheral nerve stimulation is also evolving quickly,[3,4] but again, insurance coverage is a major barrier, despite strong clinical data.
What message would you most want to share with clinicians managing surgical pain?
Pain is multifactorial. It's not just nociception — it's influenced by emotional, psychological, and social factors. Taking time to understand the patient's full experience and tailoring treatment accordingly leads to better outcomes. We now have more tools than ever to help us do that.
