Advances in ERAS to Reduce the Incidence of Chronic Post-Surgical Pain and Persistent Postoperative Opioid Use: A Narrative Review.

Abstract

Background: Chronic postsurgical pain (CPSP) remains a clinically significant complication following major surgery, contributing to long-term functional impairment, reduced quality of life, and persistent opioid use. Enhanced Recovery After Surgery (ERAS) pathways have transformed perioperative care by integrating multimodal, opioid-sparing strategies to improve acute recovery; however, their effectiveness in preventing CPSP is less clearly defined.

Methods: We conducted a narrative review of randomized controlled trials, meta-analyses, cohort studies, and clinical guidelines evaluating perioperative interventions relevant to CPSP prevention, including systemic pharmacologic agents, regional and neuraxial techniques, preemptive analgesia, and early mobilization strategies. Evidence was appraised with respect to acute analgesic efficacy, impact on CPSP incidence, safety, and feasibility within ERAS pathways.

Results: Most single-modality interventions demonstrated consistent benefit for acute pain control and opioid reduction, but limited or inconsistent effects on CPSP prevention when used in isolation. Gabapentinoids and neuraxial techniques showed little support for long-term benefit and raised concerns regarding adverse effects and recovery delays. In contrast, multimodal strategies incorporating peripheral and interfascial regional techniques, intravenous lidocaine, duloxetine in select populations, wound infiltration, and early mobilization showed more promising associations with reduced persistent pain, particularly when tailored to patient risk and surgical context. Early mobilization and effective acute pain control emerged as critical, interdependent elements influencing pain chronification.

Conclusions: Current evidence does not support reliance on any single perioperative intervention to prevent CPSP. Instead, prevention appears to require a comprehensive, mechanism-based, and patient-centered ERAS approach integrating preoperative risk stratification, multimodal pharmacotherapy, targeted regional techniques, and early functional recovery.