Long-Term Opioid Use Related to Anesthesia
The U.S. continues to face an opioid crisis, with the number of opioid deaths still on the rise. Long-term use of opioids following opioid-based anesthesia remains a significant challenge for many patients in this context. Persistent postoperative opioid use after cardiac surgery for example affects up to 1 in 20 patients 1, and approximately 40% of opioid overdose deaths involve a prescription opioid. The combined economic burden of prescription opioid-related overdose, abuse, and dependence generally exceeds $78.5 billion annually 2.
With data showing incrementally increasing opioid prescription levels being linked to stepwise increases in complication risks 3, a number of professional entities have created guidelines to reduce opioid prescriptions 4.
Entirely opioid-free anesthesia has also emerged as a more extreme option, with data showing a strong ability in some cases to reduce long-term opioid use and provide other benefits 5. Indeed, a recent systematic review and meta-analysis demonstrated that opioid-free anesthesia significantly reduced adverse postoperative events, mainly by virtue of decreased nausea and vomiting. In addition, postoperative opioid consumption was significantly lower in the opioid-free group. Meanwhile, there was no significant difference in length of post-anesthesia care unit stay and overall postoperative pain between groups, with the researchers concluding that opioid-free anesthesia improves postoperative outcomes across surgical settings, without incurring adverse effects on patient safety or pain management 6.
However, opioid-free anesthesia still raises questions. First, accurate monitoring to measure intraoperative nociception and guide the use of adjuvants is not available. Second, there remains a need to develop procedure-specific strategies in addition to specific indications and contraindications for this approach. Finally, objective assessment of opioid-free anesthesia use on patient outcomes, including both long-term opioid use and pain management, needs to be recorded in the context of large multicenter studies 5.
A recent narrative literature review sought to develop a comprehensive understanding of nociception and pain within the field of opioid-free anesthesia 7. Physiological, pharmacological, procedural (i.e. type of surgery), genetic and phenotypic factors were taken into consideration. Data revealed that vulnerable patients may benefit more from opioid-free anesthesia, with an interesting field of research pertaining to clinical patients suffering from vascular disease. Data also demonstrated that a variety of techniques and medications make it impossible to consider opioid-free anesthesia as a single technique.
The researchers concluded that recent developments in opioid-free anesthesia may offer an entirely new more holistic approach, challenging the fundamental need for opioids and their associated risk of long-term opioid use. Meanwhile, a vast field of research remains to be explored. In particular, better understanding nociception, given the variety of opioid-free anesthesia techniques, may help maximize their potential in different contexts 7.
Additional research remains to be carried out in order to elucidate the role of anesthesia in the context of long-term opioid use and the ways in which to best prevent the development of opioid use disorders following anesthesia regimens across clinical contexts. Crucial follow-up studies should be organized to shed light on the full extent of the impact of chronic opioid use on health worldwide, thereby providing tractable opportunities for intervention 4.
References
1. Liu, Z. et al. Epidemiology of persistent postoperative opioid use after cardiac surgery: a systematic review and meta-analysis. Br. J. Anaesth. 129, 366–377 (2022). doi: 10.1016/j.bja.2022.05.026.
2. Burns, S., Urman, R., Pian, R. & Coppes, O. J. M. Reducing New Persistent Opioid Use After Surgery: A Review of Interventions. Curr. Pain Headache Rep. 25, (2021). doi: 10.1007/s11916-021-00943-6
3. Cozowicz, C. et al. Opioid prescription levels and postoperative outcomes in orthopedic surgery. Pain (2017). doi:10.1097/j.pain.0000000000001047
4. Poeran, J. & Memtsoudis, S. G. Chronic opioid use and long-term mortality: a global problem. British Journal of Anaesthesia (2020). doi:10.1016/j.bja.2019.09.033
5. Lavand’homme, P. & Estebe, J. P. Opioid-free anesthesia: A different regard to anesthesia practice. Current Opinion in Anaesthesiology (2018). doi:10.1097/ACO.0000000000000632
6. Olausson, A. et al. Total opioid-free general anaesthesia can improve postoperative outcomes after surgery, without evidence of adverse effects on patient safety and pain management: A systematic review and meta-analysis. Acta Anaesthesiologica Scandinavica (2022). doi:10.1111/aas.13994
7. Goff, J. et al. Can Opioid-Free Anaesthesia Be Personalised? A Narrative Review. J. Pers. Med. 2023, Vol. 13, Page 500 13, 500 (2023). doi: 10.3390/jpm13030500.