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


Do Opioid-free Strategies Have Benefits Beyond and Above Opioid-sparing Strategies?

To date, there is no evidence. Multimodal analgesia can lead to significant opioid sparing. At this time, the clinical benefits of such limited opioid use do not outweigh the challenges and limitations associated with the suggested opioid-free strategies.

Is Complete Opioid Sparing Possible in the Context of Existing Multimodal Opioid-sparing Strategies?

Yes, but only in some contexts and procedures. Opioid use during surgery is not a must; for example, surgeries can be performed under neuraxial anesthesia or effective regional analgesia. Similarly, some outpatient procedures can be opioid-free in their postoperative period and after discharge. However, individual titration of analgesics based on patient needs is important.

Do Opioid-free Strategies Prevent Persistent Opioid use or Overprescription?

No. The existing literature does not support the hypothesis that avoidance of opioids will prevent persistent opioid use. They also have no bearing on the kind or amount of opioids prescribed at discharge.


In this article, we critically reviewed the considerations of using opioids during the perioperative period, as well as the limitations of the suggested opioid-free anesthesia and opioid-free analgesia approaches. Effective perioperative analgesia is not only a humane necessity but is important to prevent short- and long-term complications. We should avoid terminology that could be misinterpreted and temper our enthusiasm toward eliminating opioids completely with practical considerations, realistic expectations, and appropriate evidence. More importantly, we should focus on minimizing opioid use with known, safe, feasible options, adapted to individual patient needs. A framework that involves patient education, preoperative opioid minimization, use of multimodal analgesia strategies, and postoperative analgesia titrated to transitional pain needs can decrease the risk of persistent opioid use and persistent postsurgical pain.