What You Need to Know About Opioid-Sparing

For centuries, opioids have been the go-to solutions for pain. However, in the 1990s, companies reformulated and aggressively marketed painkillers like OxyContin, and overdose deaths skyrocketed. Between 1999 and 2010, the rate of opioid-involved overdose deaths more than doubled.[4]

Agencies like the National Institute on Drug Abuse point out that repeated use of painkillers can lead to tolerance and physical dependence, even when they’re used as prescribed by a doctor.[5] In response, some medical professionals are turning to opioid-sparing techniques to ensure their treatments don’t cause more harm than good.

Opioid-sparing is the practice of combining opioids with nonaddictive medications. When used together, they create an equal or comparable level of pain relief for patients with less risk of opioid-related side effects, including addiction or dependence.

How Does Opioid-Sparing Work?

Opioid-sparing is a strategy of using non-opioid medications preferentially or in conjunction with opioid medications in order to provide adequate pain relief while minimizing unnecessary risk of overusing opioid medications.[1] This can be done in the hospital setting when a patient is having acute pain, or in the outpatient setting if a patient is using opioids more long term for a chronic pain condition. 

Who Is a Candidate?

Broadly, any patient who is prescribed opioids but could see a similar level of pain relief while taking fewer opioids can be considered a candidate for opioid-sparing.

The United States is currently experiencing an opioid epidemic, with many Americans struggling with opioid use disorders (OUD). Sometimes, those struggles are tragic. In 2021, the number of reported overdose deaths involving prescription opioids totaled 16,706.[6]

Opioid-sparing has the potential to reduce the risk that a person may develop a problem with opioids while still providing the pain relief they need.

What Medications Are Used With Opioids With Opioid-Sparing?

Just as every patient is different, so is every opioid-sparing program. Doctors assess their patients carefully and pair therapies to symptoms.

Researchers say these medications are often included in opioid-sparing programs:[7]

• Acetaminophen: This medication relieves pain, and it can be used alone for mild or moderate pain. If discomfort persists, it can be combined with opioids. When combined, acetaminophen reduces the opioid dose required by 20%.
• Non-steroidal anti-inflammatories (NSAIDs): These medications work directly on pain receptors in the brain. They can be given alone or provided in combination with low doses of opioids. Some studies suggest that NSAIDs are more effective than opioids for pain control.
• NMDA agonists: Medications like dextromethorphan and ketamine alter signals moving between the brain and spinal cord. People with neuropathic pain may get more relief from these therapies than from opioids.
• Anticonvulsants: Medications like gabapentin and pregabalin aren’t designed for pain management, but they can lower how much opioids people need to be comfortable after surgery.
• Steroids: These medications can reduce inflammation and help people feel comfortable when struggling with deep wounds and infections.
• Alpha-2 agonists: Medications like clonidine are typically used to lower blood pressure, but they can help to reduce the opioid dose people need to stay comfortable.

Doctors can also use injections of local anesthetics like lidocaine to lower patient pain. Some also recommend non-pharmacological techniques like counseling and acupuncture to help patients feel comfortable without leaning on opioids.[7]

Opioid-Sparing Short Term vs. Long Term

Short-Term Opioid Sparing

Many patients who use opioids do so only short term to treat acute pain. For example, while hospitalized or after a surgery or procedure. Nonetheless, they may experience what are called opioid-related adverse effects (ORAEs). Short term effects of opioids include constipation, stomach distension and bloating, nausea, vomiting, itching, rashes, dizziness and alterations in mood. Therefore, opioid sparing – using other classes of analgesics such as tylenol, anti-inflammatories, muscle relaxers, etc. – can be helpful in providing supplemental pain relief and simultaneously minimizing these effects. 

Long-Term Opioid Sparing

As many as 6% of opioid-naïve (meaning people new to opioids) surgical patients become chronic opioid users once they take opioids, with the risk of long-term use rising the longer they are on opioids. Opioid-sparing has the potential to reduce these people’s risk of opioid use by having them use fewer opioids for less time while still getting adequate pain relief. For example, a patient who is using oxycodone three times a day could also try using a lower dose of the opioid and an anti-inflammatory medication at the same time, with the goal of obtaining a similar level of pain relief. 

Cannabinoids for Opioid-Sparing

One 2017 review explored the potential for cannabinoids in opioid-sparing. The results were mixed. Some evidence showed that cannabinoids may be useful for this purpose, but the authors stated that high-quality-controlled clinical trials need to be done to say more definitively whether cannabinoids have potential use in opioid-sparing.[2]

Creating an Opioid-Sparing Plan for Planned Procedures

Pain is a common part of medical treatments. Researchers say up to 86% of people who go through surgery experience pain following it, and less than half say they get enough relief.[7]

Ongoing discomfort can impede your recovery, so it’s critical to get care. However, it’s smart to talk with your doctor about what to expect and what to do next.

When you’re scheduling your procedure, ask your doctor questions like these:

• How much pain should I expect?
• How long will severe pain last?
• How will you treat my pain during the procedure?
• What take-home medications will I get?
• How should I use these medications?
• Will I need to taper my doses when I’m done, or can I just quit using them?

Some medical providers, including those at Michigan Medicine, use handouts to explain what level of pain people should expect after surgery and why opioids shouldn’t be the first choice.[8]

Most post-op instructions, even in opioid-sparing programs, include details about opioids. Typically, patients are encouraged to use their non-opioids first, but if they’re experiencing breakthrough pain, they can switch.[8]

If you’re given a handout like this, read it carefully and follow the instructions. Call your doctor if you have any questions or concerns about your pain.

Other Experimental Pain Medications for Opioid Sparing

A 2017 review explored methods used to decrease opioid use postoperatively. Some drugs associated with a notable opioid-sparing effect in at least some contexts included the following:

• Dexmedetomidine
• Ketamine
• Dextromethorphan
• Gabapentinoids
• Lidocaine

This review did note a lack of long-term outcome data, which is important for determining how effective a medication used for opioid-sparing might actually be in reducing a patient’s risk of developing an opioid use disorder long term. 

Opioid-Sparing: The Bottom Line

While opioids do have an important role in acute pain management, they always involve risk, and thus using opioid-sparing strategies is always important, when possible. There are a number of other medications that can be used either instead of or in conjunction with opioids, including anti-inflammatory medications, Tylenol (acetaminophen), muscle relaxers, gabapentinoids, SNRIs, lidocaine, among others.

If you are using opioids either short or long term and are interested in minimizing your risks, talk to your doctor about what other medications you could use either instead of, or simultaneously with, your opioids in order to control your pain but still minimize your risk of opioid related adverse effects.