A narrative review of opioid alternatives in rhinoplasty: a multifaceted approach, review and protocol

Introduction

Background

Traditionally, for pain management for rhinoplasty surgery patients are administered to take a regime of narcotics and outdated therapies. Research has found that nerve blocks in orthopedic operations have reduced pain and the use of opioids in patients. This has inspired Dr. Anil R. Shah (MD) to reinvent his pain management with addition of a nerve block in the face as well other therapies, multimodal anesthesia (MMA), non-opioid medications, red-light therapy, and even aromatherapy.

Rationale and knowledge gap

Recently, several protocols have been developed to enhance surgical healing and avoidance of the use of opioids for several procedures. The Enhanced Recovery After Surgery Pathway (ERAS) contains the complete progression of the patient’s surgical experience. The ERAS Pathway includes a total of six stages to create a more efficient and enjoyable surgical proceeding. These stages include (I) outpatient clinic; (II) pre-anesthesia clinic; (III) pre-operative area; (IV) recovery room; (V) impatient unit; (VI) discharge (1). Generating a fluid and effective way to care for our patients throughout their entire surgical journey is paramount to our practice. To our knowledge, there are no specific protocols in place for rhinoplasty, so the focus will be on the alternatives to pain management for rhinoplasty that tend to reduce or eliminate complications that are detrimental, timely, or costly. Furthermore, excessive opioid prescriptions after elective surgery have been established as a contributor to the current opioid epidemic, which kills more than 136 Americans daily (2).

Objective

The aim of this paper is to review the literature and examine methods for improving pain control and minimizing the use of narcotics. Based on existing papers, an updated protocol will be provided with respect to level of evidence. A patient’s comfort is of the utmost importance to a successful surgical journey, especially in terms of elective cosmetic surgery. Pain management must be optimized to reduce pain symptoms and ameliorate a patient’s recovery. Therefore, alternatives to opioids must be thoroughly examined to enhance the journey to recovery and subside pain associated with surgery. The ultimate aim of any pain management approach is to ease and facilitate the transition of a patient back to their normal everyday lives. We present this article in accordance with the Narrative Review reporting checklist (available at https://amj.amegroups.com/article/view/10.21037/amj-23-167/rc).

Methods

The findings discussed in the literature review have been applied following an implemented search strategy (Table 1). The search strategy encompasses employing credible databases, such as PubMed and Google Scholar. Search terms used to identify related research and literary work include “Rhinoplasty pain management protocol” OR “non-opioid pain protocols” AND “rhinoplasty” AND “opioid alternatives”. The accepted publication year ranged from August 1983 to October 2023. The research employed in the narrative review must be in English language or with a published translation. The selection process opted out of using publications that did not meet the previous criteria. The research was conducted by all authors and publications that were deemed appropriate and related to the objective were included in the research.

Impact of opioids on post-surgical healing

The opioid epidemic has reached alarming proportions in North America, UK, and Australia (3). The use of opioids can be dangerous for patients due to their addictive properties leading to overuse and overdose. Additionally, opioids can also portray a negative impact on a patient’s healing process. Physicians have the ability to confront this crux by exploiting alternative and non-opioid analgesics. A significant issue presently is that there is limited literature describing these safe alternative approaches for rhinoplasty, which is the main reason we will be outlining them below.

However, opioids have been found to be detrimental to patient health for a variety of reasons. One of the most dangerous effects that opioids can have on patient health is that they can cause addiction. According to the US National Library of Medicine, roughly 4% of adult Americans misuse prescription opioids (4). More than 42,000 deaths were regarded as being caused by opioids in 2016, with fatalities continuing to increase as well. Those with prescription opioids are especially vulnerable, as there is a trend of overprescribing opioids, inadvertently perpetuating addiction (5). In fact, over prescription of opioids is one of the main reasons that physicians get their licenses revoked (6). Opioid addiction is dangerous because of the risk of overdosing, changes in brain chemistry, and dependency, which can cause withdrawal symptoms like muscle cramping, anxiety, and diarrhea.

Opioids can also cause postoperative nausea and vomiting, which is typically responsible for a delay in patient recovery, prolonged patient stay in the recovery area, delayed hospital discharge and unanticipated admission to hospital, all of which increase health service costs (7). Perioperative opioid administration is also known to predispose to persistent opioid use, with its concomitant contribution to the current world-wide opioid epidemic. Opioid administration, on top of being associated with postoperative nausea and vomiting, is also associated with many side-effects such as constipation, urinary retention, and respiratory depression (8). According to the Journal of the American Association of Nurse Practitioners, about 40% of surgical patients experience nausea and 15–25% experience vomiting after being treated with opioids (9). A recent meta-analysis found that in 23 randomized controlled trials (RCTs), with a total of 1,304 patients, postoperative nausea and vomiting was reduced significantly intra-operatively and operatively in the opioid-free groups (8).

Opioids can also cause inconveniences to patients in the postoperative period due to sedation. According to the US National Library of Medicine, 20–60% of surgical patients experience sedation oftentimes during (opioid initiation or when the dose is increased) (10). The severity of the sedation ranges from mild, where the patient has normal responses and slight drowsiness, to severe, where the patient is unable to respond to most stimuli. As such, sedation can interfere significantly with the everyday life of patients. Another concern with using opioids in surgical procedures is that they are available to be stolen by staff (11).

Purdue University School of Nursing professors obtained 107 reports of drug theft from 104 long term care homes with the help of the Minnesota Department of Health between 2013 and 2021 (12). Throughout their inquiry, their group found a total of 11,328.5 tablets, a majority of which were opioids, stolen from 368 residents. A great constitution of these tablets were oxycodone and hydrocodone, which consisted of 57.5% of the stolen drugs. An alarming discovery is that close to half of the employees who stole medications were nurses. Since most cases of drug theft go unreported or incompletely filled, these statistics are likely much less than the actual number of stolen drugs. For example, in 12% of the reports, no number of stolen pills were listed, so each report counted one pill stolen even though many more pills were likely stolen.

MMA

MMA is a technique used to manage anesthesia use to avoid sole reliance on opioids (13). This is done with the aim of reducing the adverse side effects, commonly accompanied by the conventional anesthesia and further increasing its effectiveness. This technique has been advocated for as it utilizes a reduced quantity of each drug with an increased efficacy. Furthermore, this technique typically employs different types of antinociceptive agents. Combining a different agent in addition to an opioid can often spare the adverse side effect induced by opioid use (13). Optimizing the combination of a non-opioid alternative, such as: non-steroidal antidepressant drugs (NSAIDs), Alpha-2-agonists, N-methyl-d-aspartates (NMDAs), etc., and opioids can efficiently reduce the amount of opioid used as analgesic. Thereby, reducing risk of chronic opioid use and abuse while effectively the use of non-opioid pharmacological and nonpharmacological additions to anesthesia to achieve an analgesic effect and reserve heavy opioid use for extreme cases. The most commonly employed MMA technique has been the coadministration of NSAIDS and reduced opioid quantities (13).

Non-opioids alternatives

There have been significant advances in drug availability, as well as their efficacy. This enables the necessary switch away from opioid use in perioperative and postoperative pain management and sedation. There exists a crucial need to reduce excessive opioid use in surgical settings while still managing pain efficiently. Table 2 illustrates some examples of alternative medications used for analgesia in surgical settings and specifically plastic surgeries.

Acetaminophen

Acetaminophen is categorized as an analgesic, pain reliever, and an antipyretic, fever reducer since it works by changing the way the body senses pain while cooling down the body (14).

Unlike NSAIDs, acetaminophen’s pathway to receptors only occurs in the central nervous system. When the acetaminophen molecule enters the bloodstream, it is first metabolized by the liver into p-aminophenol, which easily crosses the blood brain barrier. Then the enzyme fatty acid amide hydrolase (FAAH), which is a part of a class of enzymes that creates smaller molecules from larger ones through the breaking of bonds utilizing water for this process. FAAH turns p-aminophenol into N-arachidonoyl phentolamine (AM404), which acts on cyclooxygenase (COX); anandamide; cannabinoid-1 (CB1); transient receptor potential vanilloid 1 (TRPV1); opioid, and 5-hydroxytryptamine (5-HT₃) receptors (Figure 1). Formerly, AM404 was thought to exclusively work as an analog of anandamide on CB1 receptors, but now that is known to not be the case, since it also works on the TRPV1 receptors as well (14).

Figure 1 Mechanism of action of acetaminophen. AM404, N-arachidonoyl phentolamine; CB1, cannabinoid-1; COX, cyclooxygenase; TRPV1, transient receptor potential vanilloid 1; 5-HT₃, 5-hydroxytryptamine; FAAH, fatty acid amide hydrolase.

NSAIDs can be contradictory in patients with gastric ulcers, asthma, people who are pregnant, nursing, or children under the age of 17 years, which makes it a more problematic drug to administer universally to patients. Since acetaminophen can be prescribed to people who cannot take NSAIDs, it can more broadly be prescribed and safely used as an analgesic medication.

Furthermore, intravenous, and oral acetaminophen administrations have been found to have the same clinical benefit, making it a more versatile drug useful preoperatively, perioperatively, and postoperatively (14). The evidence for this was found in an ERAS protocol for gynecologic surgery, where there was found to be no difference in terms of pain scores when comparing IV to oral acetaminophen (15). One of the main elements of the ERAS program is to limit or eliminate the use of opioids through multimodal perioperative pain management. Through the use of both IV and oral acetaminophen utilization with the combination of other non-opioid analgesic medications and techniques, we are able to limit their pain in a safer way with fewer side effects, such as nausea and altered states of consciousness.

Steroids

Glucocorticoids are known to have anti-inflammatory properties which in term helps relieve pain. Their mechanism of action for reducing pain is through the inhibition of prostaglandin synthesis. The benefit of employing steroids, glucocorticoids, is their lipid behavior and hydrophobic nature enabling a cross to the blood brain barrier. Steroids are typically employed as adjunctive analgesic in surgical settings, as opposed to a primary method of analgesia. It is used to manage pain symptoms in surgical patients with the combination of a sedative.

The use of steroids for pain management has been proven to reduce postoperative nausea and vomiting. In a recent analysis of 11 RCTs encompassing the effect of glucocorticoids on postoperative outcome, they were found to decrease complication rates. The analysis also portrayed a technique of exploiting steroids to enhance analgesia efficiency. The research showed that administering corticoids preoperatively can enhance analgesia (16).

Gabapentin

Gabapentinoids, gabapentin and pregabalin, are anticonvulsant medications most commonly employed for chronic neuropathic pain but are now implemented preemptively for many types of surgeries to reduce opioid use (17). These gabapentinoids work by inhibiting calcium-mediated neurotransmitter release, reducing the firing of action potential of pain signals to the brain. They are often thought of as the first line of defense for the management of neuropathic pain, but more recently have been advocated for as part of a multimodal anesthetic approach, in the aim of reducing opioid usage, which has been found to be effective in this aim (18). Gabapentin administration has been on the rise not only due to the reduction in opioid use but also because it reduces postoperative pain and perpetuates the analgesia period. By medicating patients with gabapentin preoperatively, there was a 35% reduction in total analgesic consumption over the first 24 hours following the surgery (19). Therefore, gabapentin reduces postoperative analgesic requirements, such as, reduced need for morphine and fentanyl.

Even though its application has great outcomes at reducing opioid use, gabapentin should be used with some caution in combination with opioids. A study of 5,547,667 surgical admissions found a significant risk of opioid overdose and opioid related adverse events when gabapentin and opioids were used in combination perioperatively. The complication could increase the likelihood of central nervous system and respiratory depression in patients (20). Gabapentin was also associated with a higher rate of delirium, new antipsychotic use, and pneumonia among older patients after surgery in another study, which looked at 967,547 participants at US hospitals aged 65 years and older. As such, gabapentin should be used with caution in older adults (20). In corroboration with this data, in a meta-analysis of 281 RCTs of gabapentin in a postoperative environment of approximately 25,000 patients there was only a slight but statistically significant reduction in opioid use and postoperative nausea though the effect size for differences in acute and chronic post-surgical pain were not clinically significant (21). Therefore, the negative side effects could potentially outweigh the benefits of medicating with gabapentin.

In some cases, gabapentin was associated with increased dizziness, visual disturbance, sedation, and risk of addiction.

NSAIDs

NSAIDs fall into the category of COX inhibitors with the aim of reducing inflammation post-operatively as well as moderate pain (21). This type of drug exerts anti-inflammatory and analgesic effects through the inhibition of the COX enzymes.

They are favored for their ease of accessibility and minimal risk of adverse effects, and they were thus added to the regimen to decrease the opioid crisis by reducing opioid consumption.

NSAIDs are often employed cautiously as it can alter platelet function, and thus affect predicted bleeding patterns. The use of NSAIDs must be done at an exact interval duration with the lowest effective dose to prevent possible complications. Furthermore, NSAIDs are administered depending on type of surgery and location as this category of drugs are known to have a ‘ceiling effect’ in relation to postoperative pain management. Nevertheless, NSAIDs have been a notorious safe and effective alternative to opioids that has inevitably reduced opioid consumptions. The NSAIDs discussed below are commonly prescribed postoperatively for pain management.

Celecoxib

Celecoxib is considered a selective COX inhibitor that falls under the category of NSAIDs. It is typically administered orally and available in varying dosages. This medication is rapidly absorbed and reaches peak levels in the blood after three hours of administration. It is considered a selective COX inhibitor as it does not inhibit COX-1 and selectively inhibits COX-2. Therefore, unlike non-selective NSAIDs, celecoxib has decreased risk of adverse gastrointestinal side effects (22).

Celecoxib has been previously administered to patients undergoing recovery post rhinoplasty and studies show a reduction in usage of oral morphine. To exemplify, Newberry et al. investigated the effect of addition of celecoxib for pain management and the results successfully showed a 76.2% reduction in milligrams opioid use (23). Another study with a sample of 994 patients conveyed that celecoxib was used intraoperatively and was not shown to increase bleeding and successfully decreased instances of nausea (24). Furthermore, celecoxib has been widely used for postoperative care in hopes of controlling opioid use and the results have been reflecting a positive experience in terms of pain management and reinforces alternative options to opioids.

Ibuprofen

Ibuprofen is a very common analgesic administered for post-operative pain, typically an oral supplement and available for intravenous administration. It has become predominantly used to manage pain related to surgery and has been effectively used to reduce opioid use. The mechanism of action encompasses the reversible inhibition of the COX enzymes, COX-1 and COX-2. The drug is administered as a racemic mixture of R and S enantiomers and these enantiomers work non-selectively in the inhibition of the COX enzymes, responsible for prostaglandins synthesis and thus blocking inflammation. Ibuprofen is also often preferred due to its efficiency of metabolism in the body. Pharmacokinetics indicate that the drug is typically fully metabolized in the body, with little to no urinary excretion of metabolites (25).

Surgeons can typically be wary of ibuprofen in the days close to the surgery, a week before or a week after and choose to hold off it. This is because of the hypothesized risk of elevated bleeding associated with inhibition of prostanoid synthesis. However, recent studies report that for most surgeries, specifically plastic surgeries, ibuprofen did not show signs of increased bleeding and the efficacy was equivalent to that of a narcotic (26). Furthermore, the drug-drug interaction of ibuprofen and anticoagulants must be closely monitored as the inhibition of COX-1 in platelets can increase risk of bleeding in association with anticoagulants and antiplatelet agents. However, a study shows low risk of adverse effects of ibuprofen administration (27).

Toradol

Toradol is considered the most potent NSAID to be used in a surgical setting as it has proven to have more efficacy (27). It has also been utilized for its availability in various forms, Toradol has the added benefit of being readily available for administration intravenously. Like other NSAIDs, Toradol’s mechanism of action involves the inhibition by COX enzymes. It inhibits the action of COX-1 and COX-2. Furthermore, unlike celecoxib, Toradol is a non-selective inhibitor as it inhibits the two cyclooxygenases.

The administration of Toradol orally is typically not preferred as it can often be harmful to the gastrointestinal system. The gastrointestinal disturbances that commonly occur include gastrointestinal bleeding, perforation, and peptic ulceration. Therefore, Toradol is preferred to be administered intravenously or intramuscularly for enhanced analgesic effect. Administering intravenously or intramuscularly increases the rate of metabolization of the drug, increasing the rate at which the analgesic effect is achieved. Unlike typical opioid analgesics, Toradol has no perceivable effect on respiration or ventilation and does not carry similar adverse effects such as nausea and vomiting. Therefore, employing Toradol can inevitably reduce the negative effects associated with typical analgesics. Bleeding time associated with Toradol is often slightly increased as it also has an antiplatelet effect. However, Toradol is used often due to its low incidence rate of adverse effects, as well as its accessibility and efficacy (28).

Alpha-2 agonists

Dexmedetomidine

Dexmedetomidine is a type of alpha-2 agonist, it is considered to display specific and selective adrenoceptor agonism. This selective and potent alpha-2-agonists was approved for sedation use in 1999 by the US Food and Drug Administration for patients in intensive care units (ICUs). This would indicate that dexmedetomidine was deemed suitable for the goal of anxiolysis and analgesia (29). The method of action of this drug encompasses that of a typical alpha-2 agonist, whereby, it instigates the presynaptic activation of the alpha-2 adrenoceptor, and this inhibits the pain signals from traveling. This inevitably moderates pain and produces analgesic effects (30). The benefit of utilizing dexmedetomidine involves the ease of sedation and analgesia without the risk of any hemodynamic fluctuation. Dexmedetomidine has also been utilized in association with rhinoplasties due to its ability to stabilize hemodynamics and achieve a higher degree of surgical satisfaction and a decreased rate of any intraoperative complications (31). However, dexmedetomidine, in comparison to opioids directly, might not suffice to ease post-rhinoplasty surgical pain. The drug would be best employed in combination with another medication for analgesia (31).

Furthermore, dexmedetomidine has had no significant complications in relation to its drug-drug interactions, in fact studies show its addition to bupivacaine to extend nerve blocks.

Dexmedetomidine can be an effective alternative to use as it can be used during the procedure preoperatively, as well as intraoperatively and can successfully decrease pain locally (32).

A study shows that dexmedetomidine has historically had more effective analgesic and sedative effects than clonidine due to its higher degree of selectivity (30). Furthermore, patients from the study results described the pain levels to have decreased as well as the adverse side effects of nausea and vomiting. Dexmedetomidine must be administered following a thorough plan for dosage and administration pathway as it is recommended to be given over at least a 10-minute interval to prevent any hypertensive episodes. Therefore, an individualized plan for dexmedetomidine must be created to optimize treatment.

Clonidine

Clonidine is the most common drug in this category in the United States. It was initially used to treat hypertension and new drug mechanisms were introduced enabling various purposes, such as opioid detoxification. Clonidine has been found to have spinal and central antinociceptive properties, making it useful as an alternative to opioids and as an analgesic. Findings from research convey that clonidine has been safe and effective to use as an analgesic with limited adverse effects (32). It has been commonly employed for the purposes of ICU sedation, as well as regional anesthesia. It is categorized as an alpha-2 agonist receptor that has been known for its analgesic properties. It is typically employed in a multimodal approach technique to augment the actions of opioids and reduce the dosage needed as well as reduce the adverse effects that accompany opioid administration.

The findings from a double-blind controlled study illustrated that an initial administration of clonidine, followed by maintenance doses, effectively provided stable anesthesia, and reduced the required morphine dosage. The difficulty with using clonidine is due to its long elimination half-life. Although clonidine has proved to have efficient analgesic and sedative properties, its long half-life prevents it from regularly being employed. The continuous usage of clonidine thus has to be monitored to optimize dosage administration. Clonidine has been initially developed for its antihypertensive properties; however, it was found to possess greater pharmacological properties that enable it to be a palatable adjunct in anesthetic practice, in addition to postoperative pain management. It is considered to be a versatile drug and can be administered in various pathways, orally, IV, etc. However, the dosage administered must be moderated and optimized for the individual (33).

Ketamine

Ketamine is described as a dissociative anesthetic and typically exploited for its effect on hyperalgesia. Its mechanism of action is fundamentally an antagonism of the NMDA receptor. Ketamine employs a specific NMDA blockade and thereby manages the responsiveness of nociceptors in the central nervous system to the surgical incision as well as to the opioid administration (34).

It can be utilized in essentially two approaches in rhinoplasty and plastic surgeries, low and high doses. At low doses, it can serve as preventative analgesia and therefore be utilized for pain management. At high doses, ketamine can provide safe and effective sedation for painful procedures, thus reducing pain intraoperatively. Ketamine can be administered in various routes which includes intravenous, subcutaneous, epidural, transdermal, and intra-articular. Therefore, making ketamine a viable option to be utilized in order to limit opioid usage and consumption.

Bupivacaine nerve block

In many ERAS protocols, the use of perioperative nerve blocks has been found to be highly effective (35). A prominent reason for reluctance for surgery can be fear of pain experienced during the recovery period. With the addition of a perioperative nerve block, patient outcomes following rhinoplasty are improved in regard to post procedure recovery room times, nausea, and vomiting. While the majority of research on nerve blocks is isolated to orthopedics, this research presents a study to disclose that nerve blocks are an effective adjuvant to surgery for postoperative pain and antiemetic effects. In his own study, a bupivacaine, a potent local anesthetic, nerve block was performed in three distinct areas along the infraorbital area bilaterally as well as in the subnasal (Figure 2).

Figure 2 Infraorbital and subnasal areas.

A total of 80 consecutive elective septo-rhinoplasty patients aged 18 to 43 years old were analyzed in this study, where 40 consecutive patients did not receive the bupivacaine nerve block and 40 consecutive patients received both preoperative and postoperative nerve blocks. The results were statistically significant with a P value <0.05 after statistical analysis was performed with an unpaired t-test. Meaning the postoperative recovery times were reduced in the group that received the nerve blocks compared to the group that did not. In general, the patients that did not receive the nerve block interventions had a post-anesthetic care unit (PACU) recovery time of 117 minutes, while the patients who did receive the nerve block had a PACU recovery time of 43 minutes on average.

Overall, these results reveal that administering nerve blocks perioperatively reduces the recovery duration an average of 74 minutes (P<0.0001). Additionally, the use of narcotics, antiemetics, and benzodiazepine were much more frequent in the group that did not receive the bupivacaine nerve blocks. Out of all the patients that were given the nerve block, only one was medicated with opioids in the PACU. On the other hand, 42% of the patients who did not receive the nerve blocks received supplemental opioids necessary to manage their pain.

Another benefit of nerve blocks that was discovered as a result of the study is their antiemetic effects. In the patients who did not receive the nerve blocks, there was a 566% increase in the use of antiemetic medication. Furthermore, there were zero complications of bradycardia, cardiovascular collapse, or central nervous system issues associated with the use of bupivacaine.

Alternative treatments

Aromatherapy

A possible perioperative adjunct that can be used alongside all of the medications touched on above is aromatherapy. Essential oils can be a tool for many therapeutic functionalities, such as, opening the nasal passageways, reduce pain, decrease inflammation, and even limit anxiety surrounding the surgery. The most effective scents are lavender and for stress and pain, and peppermint and eucalyptus for increased airflow. When you breathe in the essential oil, the scent becomes a biological signal that binds to receptor cells that line the walls of the nose. Binding to these olfactory receptors cause a signaling cascade, which leads to stimulation to parts of the brain that influence physical, emotional, and mental health. Regarding pain reduction, in a recent study in Iran, a combination of lavender and Damask rose was found to significantly reduce pain and anxiety in women with C-section compared to a control group (30). Ninety mothers were split into three treatment groups, one control, one given lavender essential oil, and the other group given Damask rose essential oil. The results show that there were not significant differences between the lavender and rose oils at reducing anxiety and pain, but when both groups were compared to the control, they did reduce anxiety and pain in the mothers. In another study, 120 patients with burns less than 30% total body surface area were given either 40%.

Damask rose oil, distilled water, or no intervention for the control group. It was found that there was a significant difference in pain intensity immediately before and after wound dressing when essential oil was used (31). Olfactory stimulation can reduce heart rate, blood pressure, temperature, and brain activity. By reducing these parameters, the body has been placed in a more relaxed and distracted state, which can lead to lower levels of pain.

In regard to airflow, eucalyptus has been effective at increasing the sensation of airflow, but unfortunately has no impact on nasal resistance to airflow, while peppermint or menthol can improve nasal airway function and overall metabolic performance when consumed with water daily (32,33). Therefore, using both of these essential oils in combination would yield the best results for improving nasal breathing after surgery.

Nasal packing

Whenever applicable, the avoidance of nasal packing is preferable. In a study, it was demonstrated that in 88 patients there was a significantly higher rate of postoperative headache and pain without a difference in septal hematoma, adhesion formation or local infection from nasal packing, as well as a higher level of pain associated with the removal of packing (34). All of these complications raise the question, “how can we avoid these negative effects?”

Alternatives to nasal packing include septal sutures and nasal cones, which not only reduce pain, but have actually been shown to be more effective at supporting the septum, although this remains controversial among medical professionals. The advantage of septal suturing over nasal packing is that it may actually have less risks including lower septal perforation, less postoperative adhesions with similar outcomes in slight oozing after surgery. The complications of septal perforation when removing traditional nasal packing can surpass the pain from the initial trauma from surgery, which can make it potentially counteractive in nature (35). In another study, avoidance of silicone splints also leads to better outcomes in pain in the early healing period compared to gauze and splints. Transseptal sutures resulted in a lower pain evaluation by the patients in questionnaires on their 2nd, 4th, and 7th days subsequent to their operation (36).

Nasal suturing can be implemented in conjunction with nasal cones, which open up the nasal passages, while supporting the septum. Cones are a revolutionary replacement to gauze and splints because while the latter close the airway, the cones allow the patients to breathe, which provides increased comfort. Therefore, the routine use of nasal packing should not be accepted as the irrefutable method of supporting the nasal septum postoperatively, when there are contemporary methods, nasal cones, and sutures, with proven benefits to their use.

Post procedure ice

Post procedure ice appears to be a useful adjunct in pain management. Common knowledge is that icing reduces inflammation, which is because the cold constricts the blood vessels and decreases overall blood circulation to the area it is applied. For optimal results in decreasing recovery time, ice the area for 15 to 20 minutes then removes the ice for 30 to 40 minutes.

Repeat this process multiple times daily until swelling has completely subsided.

In comparison to traditional ice packs, hilotherapy, which delivers chilled distilled water, 15 ℃ to the skin via an anatomically engineered facemask, was found to decrease pain. In a study examining 60 total patients, 35 women and 25 men, who had undergone rhinoplasty surgery with the same surgeon, 30 patients in a control group were treated with the conventional cryotherapy of ice packs, while the other 30 patients were treated with the hilotherapy. For consistency, both of the treatments started 45 minutes after surgery and were continued for 24 hours. Then the next week, all of the patients were examined for edema, ecchymosis, and pain. Data analysis showed that there was a lower mean of edema, ecchymosis, and pain in the hilotherapy group for the 7 days after the surgery than the ice pack group, P value <0.001 (37).

Music and binaural beats

Music can be an unconventional approach to decreasing pain. Music inevitably has an effect of reducing anxiety and providing relaxation. It enables the reduction of anxiety as the rhythm and beats have an effect on cardiac rhythms and the reduction of postoperative anxiety would be correlated with pain reduction. A study performed using a sample size of 59 patients undergoing nasal septal surgery showed significant reduction in postoperative pain, measured objectively. Pain and anxiety were decreased significantly in the perioperative period.

Music can be considered an alternative and accessible therapeutic medicine that can be easily implemented. One of the difficulties of implementing music is its relative newness, therefore, there is no protocol that exists. Furthermore, the limitation of this would be the genre of music. The rhythms and beats of the music used for medicinal therapy should be calm to moderate heartbeat as in instances of pain and anxiety the heart rate starts to increase rapidly. Mimicking the ideal heartbeat through music can enable normal and relaxed cardiac rhythms (38).

Updated protocol

The need for the reduction of opioid usage creates a need for an updated protocol. Individualized patient care is crucial to optimize patient satisfaction and enhance a patient’s individual experience. The ideal aim is to increase the communication between the physician and the patient in terms of medical therapeutics to create the most effective and efficient treatment while reducing the dosage of opioid prescribed. Table 3 illustrates the updated protocol implemented following the review of literature. Table 3 employs a combination of the alternative described pre-dosing, intraoperatively as well as postoperatively. This thorough generalized plan is created for optimized pain management and sets the ground for the transition away from opioids.

Furthermore, every patient can have a restriction to a specific category of medication and the generalized plan in Table 3 would require to be altered to their benefit. Figure 3 creates a summarized diagram of the most common medication restrictions faced in the world of plastic surgery. Some patients would be required to substitute certain NSAIDs typically used for postoperative pain management, such as Tylenol. Additionally, certain patients are often recommended to steer away from alpha 2 agonists where the intraoperative plan would need to be adjusted and sometimes even the pre-dosing plan. Therefore, there is a strong emphasis on optimizing the treatment plan for the patient to enhance pain moderation.

Figure 3 The possible alternative utilized for patients having any special medical restrictions.

Discussion

Limitations and future research outcomes

The research can be considered limited in the sense of patients’ medical histories. The research briefly touched on some commonly encountered medical histories in the selected group of patients of elected surgeries. However, it can be more thorough to include a vast variety of medical conditions that can alter the standard protocol taken to decrease opioid usage in analgesia.

The research can be considered a steppingstone for the introduction of adapted protocols for differing surgeries, whether elective or obligatory. The next step in this particular research is to expand on less encountered medical conditions and how the opioid alternatives can be adjusted accordingly, furthermore, the literature review can be amplified by discussing other surgeries conducted in the clinic. The literature review can also give a comparison on how the opioid alternatives and the multi-modal approach is often altered depending on the location and invasiveness of the surgery.

Conclusions

Although opioids are generally known as efficacious, the transition away from opioids is essential in our day today. The reduction of opioid usage is crucial to eliminate the risk of addiction and opioid abuse, as well as maintain the adverse side effects that accompany its administration. Pain management for patients must be moderated and there exists a need to develop optimized individualized plans for each patient. Many factors can impact the medicinal therapeutic plan for a patient; therefore, the optimized plan of action must take into account the holistic background of the patient, age, any allergies and medical history.

In the 21st century, there exists multitudinous viable options to be used to provide adequate analgesia. Furthermore, there are new techniques, such as MMA, that can be implemented to reduce opioid usage and manage the adverse effects associated with it. Plastic surgeons are often cautious to prescribe non-opioid medication because of the reliance we have on it as well as its ease in eradicating postoperative pain. However, this literature reviews all the possible alternatives used either as opposed to opioids or in combination with them. In multiple studies reviewed, the results from implementing non-opioid medications have been successful at achieving patient satisfaction and ameliorating pain levels. The listed alternatives are all viable options that we currently employ in a multimodal technique to steer away from opioids, and it is concluded that patient satisfaction can be achieved by employing these alternatives.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://amj.amegroups.com/article/view/10.21037/amj-23-167/rc

Peer Review File: Available at https://amj.amegroups.com/article/view/10.21037/amj-23-167/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://amj.amegroups.com/article/view/10.21037/amj-23-167/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Davis N. Improving Patient Care and Outcomes in Colorectal Surgery: The ERAS Pathway. Johns Hopkins Medicine. February 9, 2017. Available online: https://www.hopkinsmedicine.org/news/articles/2017/02/improving-patient-care-and-outcomes-in-colorectal-surgery--the-eras-pathway
2. Bustamante J. Drug overdose death Statistics [2023]: Opioids, fentanyl & more. NCDAS. January 1, 2023. Available online: https://drugabusestatistics.org/drug-overdose-deaths/
3. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy, et al. editors. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington, DC, USA: National Academies Press; 2017.
4. Skolnick P. The Opioid Epidemic: Crisis and Solutions. Annu Rev Pharmacol Toxicol 2018;58:143-59. [Crossref] [PubMed]
5. Volkow ND, Jones EB, Einstein EB, et al. Prevention and Treatment of Opioid Misuse and Addiction: A Review. JAMA Psychiatry 2019;76:208-16. [Crossref] [PubMed]
6. Gardner EA, McGrath SA, Dowling D, et al. The Opioid Crisis: Prevalence and Markets of Opioids. Forensic Sci Rev 2022;34:43-70. [PubMed]
7. Soffin EM, Lee BH, Kumar KK, et al. The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse. Br J Anaesth 2019;122:e198-208. [Crossref] [PubMed]
8. Frauenknecht J, Kirkham KR, Jacot-Guillarmod A, et al. Analgesic impact of intra-operative opioids vs. opioid-free anaesthesia: a systematic review and meta-analysis. Anaesthesia 2019;74:651-62. [Crossref] [PubMed]
9. Mallick-Searle T, Fillman M. The pathophysiology, incidence, impact, and treatment of opioid-induced nausea and vomiting. J Am Assoc Nurse Pract 2017;29:704-10. [Crossref] [PubMed]
10. Schisler RE, Groninger H, Rosielle DA. Counseling patients on side effects and driving when starting opioids #248. J Palliat Med 2012;15:484-5. [Crossref] [PubMed]
11. Cobaugh DJ, Gainor C, Gaston CL, et al. The opioid abuse and misuse epidemic: implications for pharmacists in hospitals and health systems. Am J Health Syst Pharm 2014;71:1539-54. [Crossref] [PubMed]
12. Brouk T. Purdue Nursing Researchers Analyze Medication Theft In Long-Term Care Facilities. Purdue University. May 2023. Available online: https://www.purdue.edu/hhs/news/2023/05/purdue-nursing-researchers-analyze-medication-theft-in-long-term-care-facilities/
13. Brown EN, Pavone KJ, Naranjo M. Multimodal General Anesthesia: Theory and Practice. Anesth Analg 2018;127:1246-58. [Crossref] [PubMed]
14. Ohashi N, Kohno T. Analgesic Effect of Acetaminophen: A Review of Known and Novel Mechanisms of Action. Front Pharmacol 2020;11:580289. [Crossref] [PubMed]
15. Tompkins DM, DiPasquale A, Segovia M, et al. Review of Intravenous Acetaminophen for Analgesia in the Postoperative Setting. Am Surg 2021;87:1809-22. [Crossref] [PubMed]
16. Cain KE, Iniesta MD, Fellman BM, et al. Effect of preoperative intravenous vs oral acetaminophen on postoperative opioid consumption in an enhanced recovery after surgery (ERAS) program in patients undergoing open gynecologic oncology surgery. Gynecol Oncol 2021;160:464-8. [Crossref] [PubMed]
17. Turan A, Sessler DI. Steroids to ameliorate postoperative pain. Anesthesiology 2011;115:457-9. [Crossref] [PubMed]
18. Kochhar A, Chouhan K, Panjiar P, et al. Gabapentinoids as a Part of Multi-modal Drug Regime for Pain Relief following Laproscopic Cholecystectomy: A Randomized Study. Anesth Essays Res 2017;11:676-80. [Crossref] [PubMed]
19. Park CM, Inouye SK, Marcantonio ER, et al. Perioperative Gabapentin Use and In-Hospital Adverse Clinical Events Among Older Adults After Major Surgery. JAMA Intern Med 2022;182:1117-27. [Crossref] [PubMed]
20. Verret M, Lauzier F, Zarychanski R, et al. Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain: A Systematic Review and Meta-analysis. Anesthesiology 2020;133:265-79. [Crossref] [PubMed]
21. Bindu S, Mazumder S, Bandyopadhyay U. Non-steroidal anti-inflammatory drugs (NSAIDs) and organ damage: A current perspective. Biochem Pharmacol 2020;180:114147. [Crossref] [PubMed]
22. Gong L, Thorn CF, Bertagnolli MM, et al. Celecoxib pathways: pharmacokinetics and pharmacodynamics. Pharmacogenet Genomics 2012;22:310-8. [Crossref] [PubMed]
23. Newberry CI, McCrary HC, Cerrati EW. The Efficacy of Oral Celecoxib Following Surgical Rhinoplasty. Facial Plast Surg Aesthet Med 2020;22:100-4. [Crossref] [PubMed]
24. Khan JS, Margarido C, Devereaux PJ, et al. Preoperative celecoxib in noncardiac surgery: A systematic review and meta-analysis of randomised controlled trials. Eur J Anaesthesiol 2016;33:204-14. [Crossref] [PubMed]
25. Mazaleuskaya LL, Theken KN, Gong L, et al. PharmGKB summary: ibuprofen pathways. Pharmacogenet Genomics 2015;25:96-106. [Crossref] [PubMed]
26. Kelley BP, Bennett KG, Chung KC, et al. Ibuprofen May Not Increase Bleeding Risk in Plastic Surgery: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2016;137:1309-16. [Crossref] [PubMed]
27. Forrest JB, Heitlinger EL, Revell S. Ketorolac for postoperative pain management in children. Drug Saf 1997;16:309-29. [Crossref] [PubMed]
28. Cai Y, Xu H, Yan J, et al. Molecular targets and mechanism of action of dexmedetomidine in treatment of ischemia/reperfusion injury. Mol Med Rep 2014;9:1542-50. [Crossref] [PubMed]
29. Gertler R, Brown HC, Mitchell DH, et al. Dexmedetomidine: a novel sedative-analgesic agent. Proc (Bayl Univ Med Cent) 2001;14:13-21. [Crossref] [PubMed]
30. Jouybar R, Nemati M, Asmarian N. Comparison of the effects of remifentanil and dexmedetomidine on surgeon satisfaction with surgical field visualization and intraoperative bleeding during rhinoplasty. BMC Anesthesiol 2022;22:24. [Crossref] [PubMed]
31. Kaye AD, Chernobylsky DJ, Thakur P, et al. Dexmedetomidine in Enhanced Recovery After Surgery (ERAS) Protocols for Postoperative Pain. Curr Pain Headache Rep 2020;24:21. [Crossref] [PubMed]
32. Quan DB, Wandres DL, Schroeder DJ. Clonidine in pain management. Ann Pharmacother 1993;27:313-5. [Crossref] [PubMed]
33. Veeralakshmanan P, Adshead S, Rowland R. Clonidine and Anaesthesia. World Federation of Societies of Anaesthesiologists 2019. Available online: https://resources.wfsahq.org/atotw/clonidine-and-anaesthesia/
34. Vadivelu N, Mitra S, Narayan D. Recent advances in postoperative pain management. Yale J Biol Med 2010;83:11-25. [PubMed]
35. Bajwa SJS, Jain D, Anand S, et al. Neural blocks at the helm of a paradigm shift in enhanced recovery after surgery (ERAS). Indian J Anaesth 2021;65:S99-S103. [Crossref] [PubMed]
36. Abbasijahromi A, Hojati H, Nikooei S, et al. Compare the effect of aromatherapy using lavender and Damask rose essential oils on the level of anxiety and severity of pain following C-section: A double-blinded randomized clinical trial. J Complement Integr Med 2020;17: [Crossref] [PubMed]
37. Sadeghi N, Azizi A, Asgari S, et al. The effect of inhalation aromatherapy with damask rose essence on pain intensity and anxiety in burned patients: A single-blind randomized clinical trial. Burns 2020;46:1933-41. [Crossref] [PubMed]
38. Poulsen MJ, Coto J. Nursing Music Protocol and Postoperative Pain. Pain Manag Nurs 2018;19:172-6. [Crossref] [PubMed]