Episode #267 Beyond Opioids: Revolutionizing Perioperative Pain Control

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. A couple weeks ago, we talked about a new non-opioid pain medication, Suzetrigine. It is so exciting to have another option to help treat postoperative pain especially when this new option is not an opioid and does not have the potential for addiction or organ toxicity. This week, we are returning to the June 2025 APSF Newsletter and we are still talking about perioperative pain management, but this time we will focus on opioid analgesia.

Before we dive further into the episode today, we’d like to recognize Medtronic, a major corporate supporter of APSF. Medtronic has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Medtronic – we wouldn’t be able to do all that we do without you!”

Our featured article today is “Perioperative Opioid Analgesia: Finding the Right Balance”

by Mychaela Mathews, Paul Guillod (Gill-id), and Steven Greenberg. To follow along with us, head over to APSF.org and click on the Newsletter heading. The first one down is the current newsletter. Then, scroll down until you get to our featured article today. I will include the link in the show notes as well.

We have exclusive content from one of the authors to help kick off the show today. Here he is now.

[Guillod] “ Hi, my name is Paul Guillod. I’m an anesthesiologist and pain management physician at Endeavor Health in Evanston, Illinois.”

[Bechtel] I asked Guillod, why do you feel so passionate about this topic. Let’s take a listen to what he had to say.

[Guillod] “ So this is an area where we can have a potentially lasting impact on patients beyond the immediate considerations of getting them safely through a case to the pacu. Approaching opioid sparing anesthesia invokes a broader perspective on the way we deliver care to patients. One that naturally aligns with our surgical colleagues. Or suddenly we’re speaking the same language on outcomes, complications, length of stay, return in bowel function, total opioid consumption. So I appreciate the interdisciplinary mindset it brings. We’ve seen the benefits of enacting opioid sparing, recovery focused techniques within our practice data supports it, and it’s our duty to provide the best and safest evidence-based care that we can.

As someone who also follows patients on the inpatient pain service, and in our chronic pain clinic, I see the consequences of long-term excess opioid consumption, and I’m passionate about offering safer, effective alternatives whenever we can.”

[Bechtel] Thank you so much to Guillod for introducing this important topic. Today, we are talking about keeping patients safe and comfortable during and after anesthesia care. This falls under the APSF Patient Safety Priority of Opioid-Related Harm which focuses on prevention and mitigation of opioid-related harm in surgical patients. Did you know that the ASPF has addressed this topic in 11 articles and counting in the APSF Newsletter over the past 9 years, supported a research grant on this issue, and continues to support efforts in the US Congress, Joint Commission, and regulatory agencies to promote postoperative monitoring of patients who have received opioids? There is a lot of work being done by the ASPF. And there is a lot of work that can be done by anesthesia professionals in your day-to-day practice to get the balance of opioid analgesia right, prevent opioid-related harm, and keep patients safe during anesthesia care. Let’s get into the article to find out more.

Opioid pain relief starting with morphine and increasing with the development of synthetic opioid agonists has been around since the 19^th century. That’s a long time. The benefit is potent analgesia, but there are significant side effects and adverse long-term effects as well. Recognition of these long-term adverse effects has led to a push for multimodal analgesia with reduced opioid use and even avoidance of opioids at times. A lot of work has been done in this area especially with the Enhanced Recovery After Surgery or ERAS protocols. One of the foundations of ERAS protocols is effective pain control while minimizing reliance on opioids for analgesia.

Let’s start with some figures and important considerations. There are over 50 million surgeries performed in the United States every year and following these surgeries about 60-80% of opioid-naïve patients are prescribed opioids for postoperative pain control. We know that for patients who are taking opioids prior to surgery, there are worse outcomes, worse pain scores, and higher costs. Once patients enter the perioperative period, opioid exposure can lead to continued opioid use. The rate of new persistent opioid use 90 days after surgery is about 6% even though there is consensus that longer opioid use for chronic non-cancer pain comes with increased risk and minimal benefit.

Another consideration is that there are concerning trends for opioid consumption depending on country-level income levels with many lower income populations having inadequate access to opioid medications. This is an area where anesthesia professionals are called upon to use our expertise in pain management as we work towards affordable and accessible optimal analgesia in the perioperative period for patients around the world.

Opioid-based analgesia involves pain management with opioid receptor agonists such as morphine and fentanyl or agonist-antagonist like buprenorphine. The benefits of perioperative opioid administration include quick onset, high efficacy in relieving somatic pain, predictability, and widespread availability. Adverse effects from opioid administration include postoperative nausea and vomiting, respiratory depression, bowel hypomotility or ileus, delirium, tolerance, and even increased pain through opioid-induced hyperalgesia. There is a risk for increased postoperative complications, longer hospital stays, and readmissions due to opioid administration especially at higher doses.

So, should we just decrease intraoperative opioid administration? Unfortunately, this may lead to worse postoperative pain and increased opioid consumption postop. Poorly controlled pain after surgery may increase postop complications as well as put patients at risk for chronic postsurgical pain. We really do need to deliver effective and timely pain control to help patients recover from surgery.

So, what can we do? Let’s make a plan for multimodal analgesia. This approach involves acting on multiple pathways pharmacologically and using regional anesthesia if possible to help minimize opioid administration while providing effective pain relief. Regional anesthesia adjuncts may include single-shot blocks, continuous nerve catheters, and neuraxial anesthesia. Medications options may include nonsteroidal anti-inflammatory drugs, acetaminophen, ketamine, dexmedetomidine, gabapentinoids, and local anesthetics. By using a combination of these multiple analgesics, it is possible to reduce the effective dose for each individual medication and decrease the associated side effects as well. The multimodal analgesia plan needs to be tailored for your patient to determine the appropriate medications to use. Let’s go through some examples:

• Ketamine is an NMDA receptor antagonist with direct analgesic effects as well as less central sensitization, but administration may cause dissociation and hallucinations at higher doses.
• NSAIDS decrease inflammation and pain through COX inhibition, but at higher doses can lead to gastrointestinal bleeding or renal injury.
• Dexmedetomidine is a alpha-2 agonists that enhances inhibitory pain pathways and decreases the sympathetic response to pain. Keep in mind that higher doses can lead to excess sedation, bradycardia, and hypotension.
• Suzetrigine, which we just introduced on the podcast a couple weeks ago, is a recently FDA approved non-opioid medication that acts through voltage gated sodium channel 1.8 inhibition leading to interrupted nociceptive signals in peripheral neurons.

It’s time for one of our favorite sections of any show, time to dive into the literature.

[Splash sound effect]

Our literature review question centers around opioid-free anesthesia which involves avoiding intraoperative opioid administration. There is limited high quality, robust evidence at this time, but there are some important studies that we are going to talk about now. You can find the citations in the show notes as well.

First up, a randomized controlled trial of 152 adult women undergoing laparoscopic gynecologic surgery that evaluated intraoperative ketamine and dexmedetomidine compared to sufentanil and found no significant differences in postoperative nausea and vomiting, pain scores, or opioid consumption. They did find that the opioid free group had longer time to discharge due to excess sedation.

The next study looked at 244 laparoscopic hiatal hernia repair procedures with opioid-based analgesia used for 191 procedures and opioid-free analgesia used for 53. There were no differences in postoperative pain requirements between the two groups, but the good news is that the patients in this group were significantly more likely to be discharged home on the same day. Same day hospital discharge was the primary endpoint of this study.

Next up, we have a study of patients undergoing video-assisted thoracoscopic surgery with patients in the opioid-free analgesia group undergoing paravertebral block compared to patients in the opioid-based analgesia group without a block. There were significantly decreased pain scores and 24-hour opioid consumption in the opioid-free paravertebral block group.

Let’s talk about a meta-analysis on opioid-free analgesia from 2023. Patients in the opioid-free groups have had the advantages of less postoperative nausea and vomiting and earlier return to normal bowel function, but there is an increased risk of bradycardia and there are similar postoperative pain scores and opioid consumption between the opioid-free and opioid-based groups. Based on the current evidence, the authors of this study could not recommend one strategy over the other one. We need more research in this area especially looking at quality of recovery and the benefits of opioid-free analgesia for patients with chronic pain.

We are going to switch gears slightly and move from opioid-free analgesia to opioid-sparing analgesia. This involves minimizing intraoperative opioid administration and providing multimodal analgesia. Using non-opioid medications and regional techniques as part of an opioid-sparing plan has demonstrated decreased opioid requirements and improved recovery. There is a small randomized controlled trial of patients undergoing laparoscopic cholecystectomy that compared an intraoperative dexmedetomidine infusion to placebo and found decreased postoperative morphine use, incidence of severe pain, and longer time to first rescue analgesic in the dexmedetomidine group. Opioid-sparing techniques have been studied in cardiac surgery patients and found that placement of a parasternal block as well as ketamine administration for the first 24 hours in the ICU led to similar pain scores along with significantly lower opioid consumption and decreased rates of ileus, delirium, mechanical ventilation time, and bronchopneumonia.

ERAS protocols which very depending on the surgery type and institution have incorporated many of the strategies for opioid-sparing analgesia to improve patient recovery and pain control. Implementing ERAS protocols often requires a multidisciplinary culture shift in the approach to perioperative care and pain management. There needs to be clinician education, stakeholder buy-in, and resource availability.

The APSF authors describe the ERAS implementation at their multi-hospital community-based health system. ERAS protocols were implemented across seven surgical specialties with unique interventions for improved patient education and recovery. Here are some of the results following establishing these ERAS protocols:

• Hospital length of stay decreased by one day
• Patients were more likely to be discharged within three days
• Decreased in-hospital opioid consumption by 50%
• Improved pain scores to mild compared to the prior moderate to severe pain score ratings.

There is ongoing research in this area. The ASPF article authors are performing a double-blinded randomized controlled trial to evaluate the potential benefits of opioid sparing anesthesia regimen on patients undergoing laparoscopic hernia repair when it comes to reducing discharge opioid consumption, pain scores, PONV, and hospital length of stay.

There is a call to action to continue the push towards opioid-sparing anesthesia strategies with multi-modal analgesia to improve outcomes and decrease the risks associated with perioperative opioid use. Evidence-based ERAS protocols with a focus on opioid-sparing techniques can help improve patient safety, recovery, and satisfaction. There are likely patients and certain types of surgeries that will benefit from opioid-free anesthesia techniques, but this is an area where more research is needed especially since many patients who have an opioid-free anesthetic are still prescribed opioids at discharge. Anesthesia professionals need to remain vigilant when it comes to a plan for optimal analgesia in the perioperative period to help keep patients safe and comfortable.

Before we wrap up for today, we are going to hear from Guillod again. I also asked him what he hopes to see going forward. Let’s take a listen.

[Guillod] “ So the easy answer is more robust data to refine these protocols with high quality research and eventually more widespread adoption. At the same time, we should be careful not to reduce anesthesia to fixed recipe protocols that ignore patient differences in the need for individualized care.

I hope going forward we have proactive personalized systems to identify and stratify patients who could benefit from extra support. That may mean preoperative pain plans, education around expectations. Sometimes cognitive behavior therapy or incorporating pharmacogenomic data to guide medication choices.

There’s still a lot of questions. Is opioid free anesthesia a useful goal outside of specific indications? And if not, how opioid sparing so to speak? Do we need to be in our approach to get the most value for patients? Can opioid sparing strategies reduce the incidence of chronic post-surgical pain or rates of new persistent opioid use after surgery?

So it’s an exciting time to explore how we can make a difference in these areas.”

[Bechtel] Thank you so much to Guillod for contributing to the show today. We are looking forward to the future with a more research in this area and a commitment to patient-centered perioperative pain management plan.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

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Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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