Opioid-Sparing Regimens Show Promise in Hospital Pain Management

The opioid crisis has forced clinicians to reassess how they approach pain management, particularly in hospital settings, where acute pain is frequent and the urgency to control it can result in opioid overuse. Emerging evidence suggests that non-opioid regimens, using medications such as acetaminophen, NSAIDs, gabapentin, and select antidepressants, can offer effective pain relief while limiting the need for opioids in hospitalized patients.

Angel Goenawan, MD, a hospitalist at Bayhealth in Delaware, presented a meta-analysis evaluating opioid-sparing regimens compared with opioid-prescribing regimens in 8 randomized clinical trials (2 nonsurgical, 6 surgical) at the American College of Physicians (ACP) Internal Medicine (IM) Meeting 2025, held April 3-5, in New Orleans, Louisiana. HCPLive spoke with Goenawan to learn more about the importance of looking at non-opioid pain management regimens and the findings of his meta-analysis.

HCPLive: Can you discuss the importance of trying to get to these opioid-sparing regimens, and how that’s become a greater goal in the field?

Angel Goenawan, MD: So, what we are interested in studying here is about opioid alternative regimens. As we know, the opioid crisis is now a public health issue, with increased rates of mortality due to opioid use. What we are trying to evaluate is whether analyzing multiple studies in a meta-analysis can show reduced opioid use or better pain control with alternative regimens.

We want to know if these regimens are comparable, something we can rely on, and use to deviate away from opioids. Apart from being a public health issue, prescription opioids also put patients at higher risk of developing opioid use disorder down the line. Around 9 million people misuse opioids, and 8.6 million of those misuse prescription opioids.

The topic we're focusing on is a very specific population—hospitalized patients. These patients often have acute pain issues that need addressing, and sometimes physicians feel pressured to manage that pain aggressively, which can lead to overprescribing opioids.

Can you discuss the meta-analysis and its findings?

We focused on randomized clinical trial studies and included about 8 studies. Two of those involved non-surgical populations, and the rest were surgical. This is important because, as hospitalists, we’ve seen that our surgical colleagues have developed ERAS protocols—Enhanced Recovery After Surgery. These protocols focus on perioperative and postoperative care to reduce opioid use. But opioid-sparing regimens are much less studied in internal medicine compared to surgical care. That’s why we wanted to do this study—to see if compiling both surgical and non-surgical studies would show any significant effects.

From the 8 studies included, 2 involved non-surgical patients. We found that pain control with opioid alternative regimens was actually better in hospitalized patients and also reduced opioid utilization. The total dose of opioids used was much lower compared to patients managed with opioid-only regimens.

I think this opens up opportunities for us, especially as internal medicine physicians, to do more studies in hospital settings. If we can introduce protocols based more on opioid-sparing regimens rather than defaulting to opioids, it could lead to better outcomes—improved pain control and reduced opioid exposure.

What reservations might clinicians have about non-opioid regimens?

Most clinicians are cautious about using NSAIDs, especially in sicker hospital patients. As a hospitalist caring for acute patients, I often see cases of acute kidney injury. In these cases, we’re more apprehensive about using NSAIDs as a first-line option. But there are still multiple other regimens we can use before jumping to opioids—like SSRIs, SNRIs, or Tylenol. We can create protocols that are tailored and selective. Not every patient is the same, so our pain management approach shouldn’t be either. For instance, we can set clear thresholds or contraindications. If a patient has acute kidney injury or chronic kidney disease, we typically avoid NSAIDs. But there are still many other options to explore before resorting to opioids.

Is there further research you’d like to do?

I think it’s really important that we do more research on this, ideally with larger patient populations. The thing with our current meta-analysis is that there’s a lot of variability between the studies, and only 2 of them involved medical (non-surgical) patients.

If we could expand future studies to include more hospitalized internal medicine patients across a range of diagnoses that cause pain, we could better determine if randomized clinical trials yield the same or better results—or possibly more adverse effects. That’s something we need to explore further.

Do you think we’re seeing a shift in how the field is responding to the opioid crisis?

Yes, I think so. More physicians are definitely aware now of opioid prescribing habits. Since 2016, when the CDC launched its campaign promoting opioid-sparing use, more physicians have become deliberate in how they prescribe opioids.

In fact, in one study that surveyed prescribing patterns before and after the CDC’s 2016 campaign, there was a clear trend—physicians started prescribing fewer opioids. That’s a good sign. But I think we still have a long road ahead in addressing opioid use disorder. There's definitely more work to be done, and I’m hopeful that we’ll keep moving in the right direction.

This content has been edited for clarity.