Circulation 94,429 • Volume 26, No. 3 • Winter 2012   Issue PDF

Reader Stresses Use of Multimodal Analgesia to Decrease Risk of Opioid-Induced Respiratory Depression

Rakesh Marwah, MD; Brendan Carvalho, MBBCh, FRCA, MDCH

To the Editor

We read with interest the article covering the Proceedings of the “Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respiratory Depression in the Postoperative Period” Conference, published in the Fall 2011
APSF Newsletter. We agree that prevention of opioid-induced respiratory depression (OIRD) is an unmet medical need and an ongoing national patient safety issue. We commend strategies outlined in the conference; however, we are concerned that the focus to prevent OIRD is too heavily weighted on monitoring. There was limited mention of techniques to minimize or avoid the use of opioids by utilizing multimodal treatment protocols. We write this letter to remind our colleagues of the importance of multimodal treatment modalities to prevent OIRD.

Monitoring of adequate oxygenation and ventilation is the cornerstone of ORID detection and timely treatment. However, the limitation of monitoring is that it may not prevent the problem. In keeping with Benjamin Franklin’s old adage, “An ounce of prevention is worth a pound of cure,” we believe that more emphasis should be directed toward opioid-minimizing strategies and multimodal therapies. Utilizing opioid-sparing drugs as part of multimodal pain management and administering the smallest opioid dose necessary are key to OIRD prevention.1,2 There are several non-opioid therapies that can reduce the amount of opioids consumed and therefore decrease opioid-related adverse events.3 Several new non-opioid therapeutics have recently been FDA-approved including intravenous acetaminophen (Ofirmev™), intravenous ibuprofen (Caldolor®), diclofenac liquid capsules (Zipsor®), nasal ketorolac (Sprix®), and DepoFoam® bupivacaine (EXPAREL™), a long-acting local anesthetic with analgesic effects up to 72 hours, that should be considered for perioperative treatment to reduce opioid use.

In summary, we believe that multimodal opioid-sparing or minimizing strategies should not be forgotten, and emphasized alongside adequate monitoring as key strategies in the prevention of OIRD.

Rakesh Marwah, MD
Clinical Instructor
Department of Anesthesia
Stanford University School of Medicine

Brendan Carvalho, MBBCh, FRCA, MDCH
Associate Professor
Department of Anesthesia
Stanford University School of Medicine


  1. Horlocker TT, Burton AW, Connis RT, et al. Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology 2009;110:218-30.
  2. Sultan P, Gutierrez MC, Carvalho B. Neuraxial morphine and respiratory depression: finding the right balance. Drugs 2011;71:1807-19.
  3. Marret E, Kurdi O, Zufferey P, Bonnet F. Effects of nonsteroidal antiinflammatory drugs on patient-controlled analgesia morphine side effects: meta-analysis of randomized controlled trials. Anesthesiology 2005;102:1249-60.

Disclosure: Dr. Marwah has received consulting fees and has stock options in Pacira Pharmaceuticals, the manufacturer of EXPAREL, which is mentioned in his letter.