Perioperative Opioid Administration: A Critical Review of Opioid-free Versus Opioid-sparing Approaches

Harsha Shanthanna, M.D., Ph.D., F.R.C.P.C.; Karim S. Ladha, M.D., M.Sc., F.R.C.P.C.; Henrik Kehlet, M.D., Ph.D.; Girish P. Joshi, M.B.B.S., M.D., F.F.A.R.C.S.I.


Anesthesiology. 2021;134(4):645-659. 

In This Article

Maximizing Opportunities for Anesthesiologists in Optimizing Perioperative Pain, Opioid Utilization, and Recovery

The perioperative period presents a unique opportunity for both anesthesiologists and surgeons to collaborate to improve patient outcomes and surgical recovery.[144,145] There is increasing recognition of different roles the anesthesiologist can play within the perioperative team.[145] A team approach allows healthcare providers and physicians to put the patient in the center, with a greater emphasis on patient-centered care and shared decision-making.[144] Several preoperative (patient) factors have been recognized to play a role in postoperative pain control, persistent opioid use, persistent postsurgical pain, and overall recovery.[27,146] Existing literature identifies anxiety, depression, catastrophizing-coping, preexisting opioid use, chronic pain, smoking, and frailty as some of the important factors that could be potentially addressed.[4,134,146,147] The preoperative phase gives an opportunity to assess, triage, and modify some of these factors, whenever possible (Figure 2). This engagement with the patient also provides an opportunity for the perioperative team to educate patients on pain control and in setting realistic expectations for the patient and the family.[26] This is a clear example of how patients, previously considered a passive recipient of information, can now be included as an active participant in their clinical process. At the same time, it is also suggested to manage anticipation of pain, decrease opioid use, and optimize and allow nonopioids for pain control.[4,25,148] Identifying patients at risk preoperatively allows the perioperative team to categorize and identify a framework to adapt intraoperative and postoperative care needs.

Figure 2.

Opportunities for anesthesiologists' in optimizing perioperative pain, opioid utilization, and improving recovery. Important elements in surgical phases are identified; use of a framework such as transitional pain service or perioperative surgical home can include specific roles for the anesthesiologist.

It is critical to maximize the role of locoregional analgesia during the intraoperative period, apart from utilizing multimodal analgesia (components are shown in Figure 1) taking into consideration patient- and procedure-specific factors.[4,148] Compared with systemic agents, regional blockade is most effective for controlling movement-evoked pain,[149] and every patient should receive some form of locoregional analgesia. With a wide variety of options available, there is a need for communication, planning, and collaboration with the surgical team to choose a technique that is feasible, effective, and safe and that improves recovery.[106]

Postoperatively, individual variation in postoperative pain resolution may necessitate further adjustments and additional options for pain management. Engagement of the patient, either in-person or by telemedicine, provides continued support and an opportunity to improve satisfaction. As part of the perioperative team, anesthesiologists can work with the surgical team to determine discharge prescription needs.[150–152] Although not directly relevant as part of this article, anesthesiologists playing a role as perioperative physician goes beyond managing anesthesia and pain needs and supports the emerging concept of continued postoperative care and monitoring to decrease the morbidity and mortality that can occur after discharge.[145] Specific to pain, patients at high risk or with an abnormal pain trajectory can be routed through a framework or care paradigm similar to a transitional pain service or perioperative surgical home that is patient-centered and includes management of analgesia using a multipronged approach of education, prehabilitation, and multimodal pharmacologic and nonpharmacologic approaches (Figure 2).[23,27,153] In a small observational study of 61 patients, Shechter et al.[150] report positive results from their perioperative pain program that focused on patients with chronic preoperative opioid therapy and reported reductions in opioid use and improvement in pain control and functions. Trials evaluating such combinations of interventions are being considered to address persistent opioid use.[154] Although such paradigms require involvement from many stakeholders,[23,154] they not only create opportunities for anesthesiologists to lead and participate in coordinated care but also lead to more sustainable gains on two different but contextually similar and challenging health problems.