New pain sits at the center of this dementia and brain health question.
Surgeons are switching to new pain protocols because the old playbook — write an opioid prescription and send the patient home — has proven dangerous, often unnecessary, and now clearly outdated by better alternatives. The FDA’s approval of suzetrigine (Journavx) on January 30, 2025, marked the first new class of non-opioid pain medication in over 25 years, while multimodal protocols have slashed opioid prescriptions by as much as 43.6% in orthopedic surgery without any meaningful difference in pain scores. For families navigating dementia care, where older adults face heightened risks from opioid side effects including confusion, falls, and cognitive decline, these shifts carry particular weight. The change is not happening in a vacuum.
The American Society of Anesthesiologists released updated 2026 practice guidelines strongly recommending fascial plane blocks for surgical pain relief, and the American College of Surgeons published a February 2026 bulletin specifically addressing how emerging options can help surgeons avoid prescribing opioids. Surgeons are the second-largest prescriber group of opioids in the United States, which means even modest changes in surgical pain management ripple across the entire healthcare system. This article covers the specific protocols driving the shift, including multimodal analgesia, Enhanced Recovery After Surgery (ERAS) programs, opioid-free anesthesia research, and the new non-opioid medications now available. It also addresses what these changes mean for older patients, particularly those living with cognitive impairment, and where the limitations still exist.
Table of Contents
- What Is Driving Surgeons to Abandon Traditional Post-Surgical Pain Protocols?
- How Suzetrigine Changes the Equation for Acute Surgical Pain
- What Multimodal Pain Protocols Look Like in Practice
- How ERAS Protocols Are Reshaping Hospital Stays and Recovery Timelines
- Opioid-Free Anesthesia and Its Current Limitations
- Why Precision Recovery May Replace One-Size-Fits-All Protocols
- What These Changes Mean for Brain Health and Dementia Care Going Forward
- Conclusion
- Frequently Asked Questions
What Is Driving Surgeons to Abandon Traditional Post-Surgical Pain Protocols?
The short answer is that traditional opioid-centered pain management creates problems that often rival the surgery itself. Opioids cause sedation, nausea, constipation, respiratory depression, and — in older adults with dementia or mild cognitive impairment — delirium that can permanently worsen cognitive function. The opioid crisis has forced the profession to reckon with the fact that surgical prescribing has been a major pipeline to addiction. According to the American College of Surgeons, surgeons remain the second-largest prescriber group of opioids nationally, a statistic that has galvanized professional organizations to act. At the same time, the science has caught up. Multimodal pain protocols, which combine several non-opioid medications and regional anesthesia techniques rather than relying on a single opioid, have demonstrated that most patients can achieve equal or better pain control with dramatically less opioid exposure.
In orthopedic trauma surgery, for example, multimodal protocols achieved a 59% reduction in opioids consumed during the first four days after surgery, and patients actually reported higher satisfaction scores on days one and two compared to traditional approaches. The evidence is no longer preliminary — it is reshaping standard-of-care guidelines from the top professional societies in surgery and anesthesiology. What makes 2025 and 2026 a genuine inflection point, rather than another round of incremental progress, is the convergence of new drugs, updated guidelines, and institutional infrastructure. Hospitals are not simply telling individual surgeons to prescribe fewer opioids. They are implementing system-wide ERAS protocols, investing in ultrasound-guided nerve block capabilities, and integrating new medications like suzetrigine into standardized order sets. The shift is structural, not aspirational.
How Suzetrigine Changes the Equation for Acute Surgical Pain
Suzetrigine represents something genuinely novel, not just another reformulation of existing painkillers. It works by targeting the NaV1.8 sodium channel in peripheral nerves, a mechanism entirely distinct from opioids. Because it acts on peripheral pain signaling rather than the central nervous system, it does not cause sedation, euphoria, or the cognitive fog that makes opioids particularly hazardous for older adults and anyone with existing brain health concerns. The clinical trial results are concrete. In a study of patients recovering from abdominoplasty, suzetrigine reduced the time to meaningful pain relief to 119 minutes compared to 480 minutes for placebo, a difference that was statistically significant with a P value of less than .0001. In a bunionectomy trial, meaningful relief arrived at 240 minutes versus 480 minutes for placebo, again with strong statistical significance (P = .0002).
These are not marginal improvements. They represent a halving or better of the wait time for real pain control, without any of the risks that make opioids a poor fit for vulnerable populations. However, suzetrigine is not a universal replacement for all pain management. It was approved for moderate to severe acute pain, which means it is designed for the post-surgical window, not for chronic pain conditions. Its long-term safety profile is still being established, and cost and insurance coverage remain barriers for many patients. For someone with dementia undergoing a necessary surgical procedure, suzetrigine could be a meaningful option to discuss with the surgical team — but it should be part of a broader multimodal plan, not treated as a standalone solution. Families should ask specifically whether their surgeon’s institution has added it to their formulary, as availability varies.
What Multimodal Pain Protocols Look Like in Practice
A multimodal protocol is not a single intervention but a layered strategy. A typical approach might combine a preoperative nerve block, an intraoperative local anesthetic, scheduled acetaminophen and an anti-inflammatory medication after surgery, and a low-dose opioid available only as a rescue option rather than a default prescription. The goal is to attack pain through multiple biological pathways simultaneously so that no single drug — especially an opioid — has to do all the work. The results across surgical specialties have been striking. In orthopedic sports medicine surgery, implementing a multimodal protocol reduced opioid prescriptions by 43.6% with no significant difference in pain scores at two weeks post-op. Even more notable, 45% of patients undergoing common orthopedic sports procedures required zero breakthrough opioids and still reported satisfaction with their pain management.
In total knee arthroplasty, one of the most pain-intensive elective surgeries performed, a modern multimodal protocol eliminated the need for opioids entirely for most patients. For older adults, particularly those with cognitive impairment who may not be able to reliably report pain levels or side effects, reducing opioid exposure is not just preferable — it may be essential to preventing post-surgical delirium. A specific example illustrates the practical difference. Consider a 74-year-old woman with mild cognitive impairment who needs a knee replacement. Under a traditional protocol, she might receive IV opioids in the recovery room, followed by oral oxycodone at home, with predictable risks of confusion, drowsiness, and falls. Under a multimodal protocol, she might receive an adductor canal nerve block before surgery, local infiltration anesthesia during the procedure, and scheduled acetaminophen and celecoxib afterward — with a small supply of low-dose opioid tablets available only if non-opioid measures prove insufficient. The difference in her first week of recovery could be the difference between staying oriented at home and ending up in the emergency department after a fall.
How ERAS Protocols Are Reshaping Hospital Stays and Recovery Timelines
Enhanced Recovery After Surgery programs take the multimodal concept and extend it across the entire surgical journey — from weeks before the operation through discharge and follow-up. ERAS protocols standardize everything from pre-surgical nutrition and anxiety management to intraoperative fluid balance and early post-surgical mobilization. Pain management is a central pillar, but it sits within a broader framework designed to get patients home faster and in better condition. The data across specialties is compelling, though the magnitude of benefit varies. In orthognathic surgery, ERAS reduced hospital admission rates from 83.5% to 22.2%. In cardiac surgery, ERAS protocols cut the median hospital stay from 11 days to 9 days and reduced opioid use on post-operative day two from 9.90 to 3.30 morphine milligram equivalents — a roughly threefold reduction.
For cesarean delivery, ERAS decreased opioid consumption by an average of 36.5 mg of oxycodone per patient with no change in pain scores. In thoracic outlet syndrome surgery, ERAS achieved a more than twofold decrease in length of stay. The tradeoff worth acknowledging is that ERAS protocols require significant institutional investment. They demand coordination among surgeons, anesthesiologists, nurses, physical therapists, and pharmacists. Smaller hospitals and outpatient surgery centers may lack the infrastructure to implement full ERAS programs, which means access to these benefits is uneven. A patient having surgery at a major academic medical center is far more likely to benefit from a mature ERAS program than someone at a community hospital. For families of dementia patients, it is worth asking directly whether the surgical facility uses an ERAS protocol and, if so, whether it has been adapted for older adults with cognitive impairment — because standard ERAS pathways sometimes assume a level of patient participation in their own recovery that may not be realistic.
Opioid-Free Anesthesia and Its Current Limitations
Opioid-free anesthesia, or OFA, takes the concept to its logical extreme: eliminating opioids not just from post-surgical prescriptions but from the operating room itself. Instead of the fentanyl or morphine traditionally administered during general anesthesia, OFA protocols substitute combinations of lidocaine infusions, ketamine, dexmedetomidine, magnesium, and regional nerve blocks. As of June 2025, there are 26 ongoing OFA interventional trials registered on ClinicalTrials.gov, reflecting serious research momentum. One clear benefit of OFA is a reduction in postoperative nausea and vomiting, or PONV, which is one of the most common and distressing complications after surgery. Research confirms that OFA clearly decreases PONV risk. For older adults, severe nausea can delay oral medication intake, prevent adequate hydration, and extend hospital stays — so this benefit is not trivial.
Extended-release local anesthetics that last up to 72 hours have also been introduced, further reducing the window in which patients might otherwise need opioid prescriptions to bridge the gap between surgery and tolerable pain levels. The honest limitation is that OFA’s overall superiority over opioid-based anesthesia is not settled science. Its effectiveness varies by procedure type, and not every patient or surgery is a good candidate. Some complex or highly painful procedures may still require intraoperative opioids for adequate pain control. The 26 ongoing trials suggest the medical community recognizes both the promise and the unanswered questions. Families should not assume that opioid-free means pain-free, and they should understand that a skilled anesthesiologist choosing to use a small amount of intraoperative opioid is not failing — they may be making the right call for that specific patient and procedure.
Why Precision Recovery May Replace One-Size-Fits-All Protocols
Even as ERAS and multimodal protocols become standard, leading researchers are already pushing for the next evolution. JAMA Network Open has called for a shift from standardized ERAS protocols toward precision-based, individualized recovery pathways. The logic is straightforward: a 40-year-old athlete recovering from ACL surgery and an 80-year-old with Alzheimer’s disease recovering from a hip fracture repair have fundamentally different pain biology, cognitive reserves, and recovery trajectories. For the dementia care community, this shift toward individualization is particularly important.
Standardized protocols sometimes assume patients can self-report pain accurately, participate in early mobilization programs, and manage complex medication schedules at home. Patients with moderate to advanced dementia often cannot do any of these things reliably. Precision recovery pathways could account for cognitive status as a variable when designing pain management plans, adjusting medication choices, monitoring frequency, and caregiver support accordingly. This is still an emerging concept rather than widespread practice, but it signals where the field is heading.
What These Changes Mean for Brain Health and Dementia Care Going Forward
The convergence of new drugs, updated guidelines, and institutional protocols creates a genuinely different landscape for older adults facing surgery. Ultrasound-guided nerve blocks and regional anesthesia have improved both precision and safety, enabling faster discharge and opioid-sparing outpatient care that keeps vulnerable patients out of the hospital environment where delirium risk compounds.
The American Society of Anesthesiologists’ 2026 guidelines strongly recommending fascial plane blocks for both open and minimally invasive procedures reflect a profession-wide commitment to these techniques. For families caring for someone with dementia, the practical takeaway is that the conversation with the surgical team should now include specific questions: Does this facility use ERAS protocols? Is a multimodal pain plan standard here, or do I need to request one? Has the anesthesiologist considered regional anesthesia options? Is suzetrigine appropriate and available for this patient? These are no longer fringe requests. They are aligned with current evidence and professional guidelines, and any surgical team that dismisses them outright may not be keeping pace with the standard of care.
Conclusion
The shift away from opioid-centered surgical pain management is no longer aspirational — it is underway and accelerating. FDA-approved alternatives like suzetrigine, multimodal protocols that have cut opioid prescriptions by nearly half in some specialties, ERAS programs that are shortening hospital stays across surgical disciplines, and 26 active clinical trials exploring opioid-free anesthesia collectively represent the most significant change in post-surgical pain management in a generation. For older adults and those with cognitive impairment, these advances are not just welcome — they address risks that the traditional approach has imposed on the most vulnerable patients for decades. Families and caregivers should bring these developments into their pre-surgical planning conversations.
Ask about the specific pain protocol the surgical team plans to use. Ask whether opioid alternatives have been considered. Ask how the plan accounts for the patient’s cognitive status. The evidence supporting these newer approaches is robust, the professional guidelines have been updated to reflect it, and patients — especially those whose brains are already under siege from neurodegenerative disease — deserve the benefit of pain management that no longer treats opioid side effects as an acceptable cost of doing business.
Frequently Asked Questions
Is suzetrigine (Journavx) safe for older adults with dementia?
Suzetrigine targets peripheral nerve sodium channels rather than the central nervous system, which means it does not cause the sedation or cognitive fog associated with opioids. However, it was only approved in January 2025, so long-term safety data in elderly populations with cognitive impairment is still limited. Discuss it with the surgical and geriatric care team as part of a broader pain management plan.
Can a patient with dementia participate in an ERAS protocol?
ERAS protocols can be adapted for patients with cognitive impairment, but standard versions often assume the patient can self-report pain, follow instructions for early mobilization, and manage medications independently. Families should ask whether the facility has experience modifying ERAS for dementia patients, and whether additional caregiver support is built into the plan.
Do multimodal pain protocols eliminate opioids entirely?
Not necessarily. Multimodal protocols dramatically reduce opioid use — by 43.6% in orthopedic sports medicine and 59% in orthopedic trauma surgery in published studies — but most keep a small opioid supply available as a rescue option. In some cases, such as total knee arthroplasty, the majority of patients end up needing no opioids at all, but this varies by procedure and patient.
What should I ask the surgeon before my family member’s operation?
Ask whether the facility uses a multimodal pain protocol or ERAS program, whether regional anesthesia or nerve blocks will be used, whether non-opioid medications like suzetrigine are available, and how the pain plan will be adjusted for a patient with cognitive impairment. These questions align with current 2026 guidelines from the ASA and ACS.
Are opioid-free anesthesia protocols widely available?
Not yet. While 26 interventional trials are currently underway and the approach shows clear benefits for reducing postoperative nausea and vomiting, opioid-free anesthesia is not standard practice at most facilities. Its effectiveness varies by procedure type, and availability depends on the anesthesiologist’s training and the institution’s resources.
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For more, see Alzheimer’s Association — medical tests.
