Efficacy and safety of regional blocks and multimodal analgesia in psychiatric patients at risk of opioid misuse: A systematic review

Abstract

BACKGROUND

Patients with psychiatric diagnoses who are subjected to surgical treatments are at risk of abusing and becoming dependent on opioids, which requires alternate measures to manage pain. One might expect that regional blocks and multimodal analgesia can be effective solutions to minimizing opioid exposure without failing to treat pain somehow in the perioperative period.

AIM

To determine the efficacy and safety of regional blocks and multimodal analgesia in patients with psychiatric disorders at risk of opioid misuse.

METHODS

This systematic review was conducted based on the PRISMA 2020 guidelines. We searched electronic databases for randomized controlled trials (RCTs) and observational studies that investigated regional blocks and multimodal analgesia in psychiatric patients or individuals at risk of misusing opioids. Quality of studies was evaluated by two independent reviewers applying the Cochrane Risk of Bias tool for RCTs and the Newcastle-Ottawa Scale for observational research. Analysis of the quality of evidence was conducted using the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

Nine of the studies were RCTs, and ten observational studies met the inclusion criteria. Multimodal strategies that were associated with highly positive opioid reduction (30-70 percent) were regional blocks, systemic lidocaine, esketamine-dexmedetomidine combinations, and magnesium sulfate. These findings were established in actual practice using observational studies, especially in the trauma and colorectal surgical groups. The recovery rates were higher, and the scores for quality were non-significantly improved using opioid-sparing procedures. An inter-reviewer agreement was found to be substantial (κ = 0.82).

CONCLUSION

Regional blocks and multimodal analgesia result in an effective reduction in the use of opioids without compromising pain control in the high-risk population. Nevertheless, there is a lack of precise evidence in psychiatric patients, and that is why this study should be conducted to investigate this vulnerable group.

Keywords: Regional anesthesia; Multimodal analgesia; Psychiatric patients; Opioid misuse; Systematic review

Core Tip: Regional blocks and multimodal analgesia reduce perioperative opioid use while preserving effective pain control. These approaches benefit surgical patients at high risk of opioid misuse including those with psychiatric illness. Evidence specific to psychiatric populations remains limited and optimal strategies should be tailored to the psychiatric profile surgical context and long term risk of dependence.