Amid the continuing opioid epidemic, anesthesiologists have a significant role to play in reducing the risk of postsurgical dependence by working perioperatively with surgeons and other providers.
This includes managing patients through approaches such as neuraxial anesthesia, regional blocks such as nerve catheters that patients can go home with and other non-opioid adjuvant modalities.
“Our goal is always to help our surgical colleagues and patients with pain management,” says Pamela A. Chia, MD, a UCLA regional anesthesiologist. “We have found that through a balanced, multimodal approach that relies on non-opioid adjuvants, along with regional and neuraxial techniques, we can minimize — and in many cases eliminate — the use of opioids for our patients.”
Dr. Chia notes that the desire among physicians to sufficiently treat their patients’ pain led to what is now acknowledged to have been an overprescribing of opioid pain relievers beginning in the late 1990s — providing fuel for the beginning of an epidemic that resulted in an estimated 450,000 deaths from prescription and illicit opioids in the United States between 1999 and 2018, according to the U.S. Centers for Disease Control and Prevention.
“We know that when they’re used safely, opioids can be very effective for pain management,” Dr. Chia says. “But through research, we also know that there has been an overreliance on opioids after even small surgeries, and there is a realization that we need to be more judicious about their use.” In addition to the risk of dependence, opioids carry side-effect risks that include nausea, pruritus, respiratory depression and constipation. Adverse reactions to opioids can lead to prolonged hospital stays, increasing the burden on the health care system.
Dr. Chia, who as a regional anesthesiologist works closely with orthopaedic surgeons, explains that for joint replacements, she and her surgical colleagues typically give non-opioid adjuvants preoperatively; they then will use a neuraxial technique, as well as a regional block that can carry over to the postoperative period, helping to reduce the need for opioids after surgery. “Every patient is different, but if we can use the non-opioid adjuvants we have, such as NSAIDs, acetaminophen, gabapentinoids and muscle relaxants, we can minimize the amount of opioids that patients are prescribed,” Dr. Chia says.
Providing opioid-free anesthesia requires a coordinated effort among surgeons, anesthesiologists, hospitalists, social workers, pharmacists, nurses and ancillary staff. “There has to be a great deal of planning, including laying the groundwork weeks in advance through patient education,” Dr. Chia notes. “It is important to manage patients’ expectations and ensure that they understand what we’re going to be doing and why.”
Opioids aren’t withheld from patients when non-opioid approaches are insufficient to relieve their pain, Dr. Chia says. “That option is always available, and as long as they are used safely and judiciously, it is appropriate,” she explains, noting that the decision on when to move to opioids is made on a case-by-case basis, taking into account patients’ level of risk and previous opioid use.
“Our goal is to manage each patient individually and to make sure that their pain is well controlled,” Dr. Chia says. “No one wants patients to suffer just to avoid opioids; in fact, when patients get behind on pain rather than managing it with small amounts of medication, it can be a problem, because they might end up playing catch-up with a larger dose. But the use of regional techniques has been terrific, and for most patients we can provide good pain relief without the use of opioids.”
To read a review by Dr. Pamela A. Chia on opioid-free anesthesia in the August 2020 issue of Current Opinion in Anesthesiology >