This perioperative protocol enhances recovery after surgery and reduces or eliminates the need for opioids.

Opioid-free anesthesia, also known as opioid-sparing anesthesia, refers to a method of administering anesthesia that reduces or eliminates the use of opioids or narcotic pain medications. Opioids, such as morphine and fentanyl, are commonly used in anesthesia because they can reduce pain and induce a state of relaxation.

Opioids come with a range of potential side effects, including respiratory depression, exacerbation of obstructive sleep apnea, nausea, vomiting, ileus, hyperalgesia (increased sensitivity to pain), drowsiness, delirium, hypotension, urinary retention, and the risk of tolerance and addiction. These adverse effects can significantly interfere with recovery and readiness for discharge and can be life-threatening.

In addition, there is growing concern about the opioid epidemic in the United States and the crucial role that over-prescribing of these drugs has played.  Some studies suggest over half of individuals with opioid abuse or dependence have their first exposure via prescription or perioperative opioid medication.

Over the past two years, the Trumbull anesthesia team has developed a perioperative protocol for enhanced recovery after surgery (ERAS) that has allowed us to offer opioid-free or opioid-sparing anesthesia care to patients in all our surgical service lines.  This approach involves multi-modal analgesia (MMA) using a combination of non-opioid medications; regional anesthesia with long-acting local anesthetics to reduce or eliminate the need for opioids; and additional interventions to enhance recovery and reduce the risk of postop nausea and vomiting.

Some of the non-opioid medications used in opiate-free anesthesia (OFA) include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, celecoxib, and acetaminophen; steroids such as dexamethasone; anticonvulsants such as gabapentin and pregabalin; local anesthetics such as lidocaine, ropivacaine, and bupivacaine; analgesics such as tramadol, ketamine, and magnesium; and alpha-2 agonists such as clonidine and dexmedetomidine. These medications can be given before, during, and after surgery to help manage pain and reduce the need for opioids.

Regional anesthesia is an important adjunct. This involves injecting local anesthetic medication near a specific nerve or group of nerves to numb a specific area of the body. This can be used to provide pain relief during and after surgery without the need for opioids.

OFA has several advantages over traditional opioid-based anesthesia. Patients may experience fewer side effects and a shorter recovery time, and the risk of opioid addiction is reduced. In addition, studies have shown that it is possible to achieve similar levels of pain management with opiate-free anesthesia as with traditional opioid-based anesthesia. A preliminary review of medication use and patient outcomes at Trumbull Regional comparing 2019 to 2022 suggests the following:

• Hospital-wide 40% decrease in fentanyl use
• Intraoperative 5 ml fentanyl usage down 86%
• Recovery room use of fentanyl down 20%; morphine, 90%; hydromorphone, 68%
• Recovery room need for antiemetics less than 2% of patients
• Recovery room need for opioid pain medicine 7%

While opiate-free anesthesia is a promising approach to pain management, it may not be appropriate for all patients or types of surgery. Patients with a history of opioid addiction, suboxone treatment, or chronic pain may require a different approach.  These patients especially may benefit from assessment, education, and medication management days to weeks prior to surgery.  Some surgeries may require the use of opioids. It is important that patients discuss their options with their doctor and anesthesia team to determine the best approach for their individual needs.

ABOUT ARTICLE CONTRIBUTOR

Sarah Aronson, MD is an Anesthesiologist at Trumbull Regional Medical Center.  She is board certified by the American Board of Anesthesiology and the National Board of Echocardiography.  Dr. Aronson attended Brown University for Medical School and completed her residency at Case Western University Hospitals of Cleveland.  Her areas of special interest include cardiac anesthesia/TEE, enhanced recovery after surgery, and opioid-sparing anesthesia.