Methadone and Enhanced Recovery After Surgery: Concepts and Protocols

A recent Pro-Con article 1 and an accompanying editorial 2 bring to the fore the use of methadone in the perioperative period.This is timely and important.Methadone is frequently studied, oft reviewed and yet habitually misunderstood.The Pro-Con addressed enhanced recovery after surgery (ERAS) protocols, but not greater considerations of the ERAS concept.ERAS conceptually has goals of earlier recovery of organ function, restoration of physiology and global function, mobilization, safe hospital discharge, and early recovery of independence, and is principally based upon minimally invasive surgery, oral nutrition and prevention of prolonged fasting, optimal fluid management, minimizing drains and tubes, early ambulation, effective analgesia, and epidurals for open procedures, to achieve early postoperative recovery. 3,4This concept is important and laudable.Who wouldn't endeavor to provide enhanced recovery for every patient?The problem is that >80% of patients report postoperative pain, most of which is moderate-severe, 50% say their pain is inadequately treated, and 10-80% develop chronic postsurgical pain, for which acute postoperative pain is the single greatest perioperative risk factor. 5,6AS protocols, per se, have proliferated, typically address and prescribe far more than the original core elements, 7,8 often without an evidence base, have become institutionalized, and yet vary vastly across institutions.ERAS protocols are often based on multimodal nonopioid polypharmacy (perioperative gabapentinoids and intraoperative bolus or infusions of esmolol, ketamine, lidocaine, magnesium, dexmedetomidine, acetaminophen), strict opioid avoidance, and good intentions, yet less evidence of efficacy and safety 8 .Using opioids or not was not part of early ERAS concepts, which also did not inform on whether opioids delay or enhance early recovery. 7Opioid-free anesthesia protocols have been said not to have benefit above and beyond opioid-sparing strategies, and, that there are insufficient data to determine benefits and harms of opioid-free intraoperative anesthesia and postoperative analgesia compared to opioid-sparing and rational opioid use. 9,10Indeed, insufficient analgesia may result in poorly controlled postoperative pain, and risk of developing chronic