September 29, 2020Open Access
Perioperative Opioid Administration
Key Result
Opioid-free strategies have significant evidence gaps, do not allow analgesic titration based on patient needs, and do not decrease the risk of persistent opioid use.
Structured PICO
Do opioid-free strategies improve perioperative analgesia and reduce persistent opioid use compared to traditional or opioid-sparing strategies?
P
Population
Patients requiring general anesthesia and perioperative analgesia
I
Intervention
Opioid-free strategies (combination of known analgesics and adjuvants)
C
Comparator
Opioid-sparing or traditional opioid-based strategies
O
Outcome
Pain control and risk of persistent opioid use
Opioid-free perioperative strategies have significant clinical limitations and do not appear to reduce the risk of persistent opioid use compared to opioid-sparing approaches.
Abstract
Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms.