Despite the millions of surgeries performed every year around the world, postoperative pain remains prevalent and is often addressed with inadequate or suboptimal treatments. Chronic postsurgical pain is surprisingly prevalent, and its rate varies with the type of surgery, as well as with certain patient characteristics. Thus, better clinical training is needed as well as patient education. As pain can be caused by more than one mechanism, multimodal or balanced postsurgical analgesia is appropriate. Pharmacological agents such as opioid and nonopioid pain relievers, as well as adjuvants and nonpharmacologic approaches, can be combined to provide better and opioid-sparing pain relief. Many specialty societies have guidelines for postoperative pain management that emphasize multimodal postoperative analgesia. These guidelines are particularly helpful when dealing with special populations such as pregnant patients or infants and children. Pediatric pain control, in particular, can be challenging as patients may be unable to communicate their pain levels. A variety of validated assessment tools are available for diagnosis. Related to therapy, most guidelines agree on the fact that codeine should be used with extreme caution in pediatric patients as some may be “rapid metabolizers” and its use may be life-threatening. Prehabilitation is a preoperative approach that prepares patients in advance of elective surgery with conditioning exercises and other interventions to optimize their health. Prehabilitation may have aerobic, strength-training, nutritional, and counseling components. Logistical considerations and degree of patient adherence represent barriers to effective prehabilitation programs. Notwithstanding all this, acute postoperative pain represents a clinical challenge that has not yet been well addressed. Approximately 80% of those who undergo surgical interventions report acute postoperative pain and, of that population, 75% state that pain intensity is moderate to severe or worse . The armMethodologyThis paper is a narrative review based on presentations by the authors at the second annual meeting of “Past, Present, and Future in Pain Medicine” held in Tunis, Tunisia, on May 11 to 13, 2023. It is a narrative review with clinical observations from the speakers/authors.ResultsBetter Management of Acute Postoperative PainPostoperative pain may be counted among the most concerning of the many worries preoccupying preoperative patients, with about half of the patients awaiting elective surgery stating they suffered “high” or “very high” anxiety about the pain they might experience after the operation . Such feOf course, there is no one-size-fits-all postoperative pain protocol. Specific groups of patients pose a particular challenge in pain management, such as patients who are pregnant, geriatric, neonatal, and opioid-tolerant patients, as well as those with hepatic/renal disease or active substance use disorder . AmbulatThe incidence of chronic postsurgical pain (CPSP) varies by type of surgery, but is surprisingly common, ranging from 10% to 70% ,7. In soEpidural analgesia can inhibit rehabilitation and hinder enhanced recovery after surgery (ERAS) protocols. There are several techniques that can be used to replace epidural analgesia, including, but not limited to, peripheral nerve blocks, catheter wound infusion, and other techniques of regional anesthesia . OutpatiA growing body of evidence supports certain alternatives to epidural analgesia. A meta-analysis of 18 studies (n = 777) reported that paravertebral block was significantly superior to epidural analgesia in the first 24 hours after surgery in terms of reducing urinary retention rates, postoperative nausea and vomiting, and hypotension, but pain relief and the rate of pulmonary complications were similar over the first 48 hours after surgery . In metaInformed consent requires that patients be apprised of the risks as well as benefits of proposed medical treatments, including surgeries . Yet, maTo reduce the barriers to better postoperative pain control, several specialties must converge, including surgery, anesthesiology, and acute pain services.Surgery: When appropriate, surgeons should favor minimally invasive surgeries and employ nerve-sparing techniques. Unnecessary surgical interventions should be avoided.Anesthesiology: Anesthesiologists should use regional anesthesia when appropriate, avoid ultra-short-acting opioids, deliver effective multimodal postoperative analgesia, and educate patients before surgery about what to expect in postoperative pain and the risk of CPSP.Acute pain services: This service should screen for high-risk patients, follow patients after surgery, and make appropriate referrals to mental health, rehabilitation, or addiction specialists, when necessary.Based on the Orebro acute pain services model, ward nurses can play an important role in pain management, including the administration of intravenous opioids and dose adjustments within prescribed limits, initiation of patient-controlled analgesia when appropriate, carrying outstanding orders for analgesic-associated adverse effects, and monitoring pain scores. There must be a collaboration between the surgeon and the anesthesiologist as well as the nursing staff for optimal results .Multimodal Analgesia for Postsurgical PainImproving postoperative pain care should go beyond informed consent and education for patients and extend to organizational shifts in hospitals, making them more receptive to patient input, more accommodating to relevant new technologies, and prioritizing round-the-clock acute pain services . HospitaAs pain, including acute postoperative pain, is multifactorial, it cannot always be adequately addressed by a single analgesic product with a single mechanism of action . Pain isTreating postoperative pain requires attention at all points of the patient’s journey, from preoperative education of the patient and risk assessments to intraoperative analgesic techniques, from postoperative anesthesia care unit protocols to pain control in the ward during recovery and prescription analgesics and instructions for home pain control upon patient discharge . The WorPrescribing choices for nonopioid agents include paracetamol (acetaminophen) and NSAIDs  ,41. OpioNSAIDs are a broad class of agents and have been linked to bleeding risk, gastrointestinal side effects, and a risk for cardiovascular adverse events . DexketoSimilar to NSAIDs, opioids are a broad class of drugs. Tramadol’s dual mechanisms of action make it a unique, even atypical, opioid analgesic . TramadoIn arriving at multimodal postoperative pain management regimens, it is important to properly combine drugs to achieve maximum benefit with minimal adverse events  together with the American Society of Anesthesiologists (ASA) and the American Society of Regional Anesthesia and Pain Medicine (ASRA) organized an interdisciplinary expert committee to develop an evidence-based guideline for postoperative pain management in adult and pediatric patients. Their findings were then approved by the American Society for Regional Anesthesia to create a clinical practice guideline published in 2016 . In 2019A retrospective database study of 2,340,462 patients undergoing total hip or knee arthroplasty found 86.4% were administered multimodal postoperative analgesia, and those on multimodal regimens had significantly fewer respiratory and gastrointestinal adverse events, consumed significantly fewer opioids, and had a shorter length of stay compared to patients receiving opioid monotherapy . AnotherThe safest, most effective, and best tolerated multimodal analgesic combinations depend on the type of surgery, the patient, and likely other factors such as the duration of the procedure and patient comorbidities. Most multimodal combination regimens are based on an opioid/nonopioid analgesic combination, whereby the nonopioid pain reliever may be an NSAID or paracetamol (acetaminophen). A gabapentinoid may be added. In some cases, intravenous ketamine or lidocaine may be appropriate in the immediate inpatient postoperative period . OpioidsThe postoperative analgesic strategy should commence before the operation with a physical and psychological assessment of the patient, including current medications, comorbidities, chronic painful conditions, and determining if the patient has a history or active substance use disorder. Prior surgical history and response to pain medications can also be helpful. The patient’s pain levels should be assessed at baseline and throughout treatment using a validated instrument, such as a visual analog scale. Multimodal analgesic regimens are preferred , and patThe European Medicines Agency (EMA) has issued specific guidelines for pain control in children. Codeine is to be used with caution and only in those over age 12 when other nonopioid pain relievers are ineffective. Note that the EMA states codeine should not be used by patients under the age of 18 years who are undergoing tonsillectomy and/or adenoidectomy, as these patients are already at an elevated risk for respiratory complications . The FooPediatric Postoperative Pain ControlIn the United States, 27% of pediatric patients in the hospital had moderate-to-severe pain, and the rates were the highest among teens (38%) and infants (32%) . GeograpMany myths surround pediatric pain management, even among clinicians. There is a debunked but long-standing myth that children are unable to feel pain. It is known that the neural pathways of pain perception function as early as 24 weeks of gestation . Some clOther barriers to effective treatment of acute postoperative pain in pediatric patients involve deficits in clinician training. Physicians and nurses often underestimate pain in infants and overestimate the risks of opioids . PrescriPediatric pain assessment can be very challenging  plus clonidine 1 µg/kg with or without epinephrine, a study of infants undergoing surgery was successful in 89% of patients and provided anesthesia appropriate for procedures lasting from 60 to 100 minutes .Prehabilitation in Perioperative MedicineThe neuroendocrine and the inflammatory-immune responses are the two primary forms of stress response to major surgery. As tissue injury triggers cytokine release, minimally invasive surgery and central neural blockade can inhibit cytokine production as a stress response, but general anesthesia has little to no influence on cytokine production. There is a normal metabolic response to surgery in the form of hypermetabolism and hypercatabolism, which converts hepatic glycogen to glucose, at the same time that proteolysis affects skeletal muscles and lipolysis recruits from fat reserves. These various energy sources are necessary for postsurgical tissue repair. The consequences of these multiple surgical responses are increased serum glucose levels, increased plasma fatty acids and amino acids, and protein catabolism . Thus, eThe evaluation of patient fitness before surgery allows for a program to help improve patient health and fitness and reduce surgical risks . By boosPrehabilitation protocols may be individualized to meet the specific needs and goals of the individual patient. Exercise regimens should vary in modalities and intensities based on the patient’s fitness level and specific needs. While some exercise programs rely on supervised instruction, other exercise protocols may allow for unsupervised exercise or hybrid programs. As a general rule, the exercise component of prehabilitation should consist of both aerobic exercise and strength training. This program can be supplemented with motivational interviewing, reflective listening, and recommendations to help patients overcome their personal barriers to better physical fitness. It may be helpful to encourage patients to increase their overall level of physical activity in daily life in addition to their exercise program.Prehabilitation should include a nutritional component and a patient education intervention. The synergistic effects of exercise and nutrition to promote anabolism are well studied. Prehabilitation uses this synergistic effect to maximize the effect of exercise on functional capacity, as well as to promote an increase in muscle mass and function that will contribute to the body’s reserve before surgery. Emphasis on balanced meals with enough adequate protein intake and blood glucose management for diabetic patients are the bases for the nutritional component of prehabilitation.Moreover, prehabilitation programs may incorporate psychosocial interventions, such as mindfulness meditation, deep-breathing techniques, and relaxation methods. Preparing for surgery is not just a physical endeavor, prehabilitation may also guide the patient to actively participate in the psychological preparation for the surgical journey. Patients should share in decision-making and be fully informed about the risks and benefits of their upcoming surgery . The medAll of these things necessitate a multidisciplinary team with good intercommunication. Depending on the patient’s condition and specific needs, this team may include a case manager, nutritional consultant, psychologist or counselor, physiotherapist, and anesthesiologist/surgeon team. Prehabilitation begins with a baseline assessment of patients, including their functional, nutritional, and psychosocial status plus an evaluation of their lifestyle, including current level of physical activity, smoking and drinking habits, and their living situation in terms of caregivers and support. This initial baseline assessment must also take into account the patient’s comorbid conditions.Prehabilitation can improve perioperative function, postoperative recovery, and outcomes, even going beyond the immediate postoperative period . PrehabiThere are often barriers to mainstreaming prehabilitation in clinical practice, although prehabilitation can be beneficial to the hospital. A prospective study in a single tertiary care hospital found in a per-protocol analysis that patients who completed prehabilitation programs had a significantly reduced mean length of stay, and those who underwent the most aggressive surgeries had a significant reduction in the length of stay in the intensive care unit. The mean cost savings generated per patient with prehabilitation versus controls was 3,093 euros . ImplemeIn this connection, it is important to recognize that surgical risks vary from low to moderate to high and these risk strata may necessitate somewhat different approaches (see Table DiscussionDespite the marked decrease in nonessential surgeries during the pandemic, the rate of surgeries around the world has rebounded and will likely continue to increase . In the Specific recommendations for postoperative pain control regimens exceed the scope of this work but vary depending on surgical as well as patient factors. The surgical factors include the type of surgery, how invasive is it, surgical duration, and perioperative pain management. Patient factors include the patient’s overall health, frailty, comorbid conditions, and psychological factors such as catastrophizing. Effective and safe pain control following surgery is possible using a multidisciplinary approach with balanced analgesia.Acute postsurgical pain is prevalent and often undertreated despite our analgesic armamentarium. A surprisingly high proportion of acute postsurgical pain can transition to chronic postsurgical pain, which is not only challenging to treat but also exposes patients to pain that may last for a minimum of two to three years, and in others for the rest of their lives. Balanced or multimodal analgesia can be beneficial in that it addresses multimechanistic pain with agents with different and ideally synergistic mechanisms of action. Dexketoprofen and tramadol combinations have been demonstrated safe and effective for managing many forms of acute postsurgical pain, but analgesic regimens must be tailored to meet the individual needs of the patient. Analgesic choices should be based on guidelines and evidence but combined, sometimes with nonpharmacologic means or prehabilitation strategies, to personalize analgesic strategies. Further study is needed for treating postoperative pain in general and in specific special groups, such as the neonatal and pediatric populations.