Debate: opioid-free anaesthesia: ideal or utopia?

Monday 5 June, 08h30-09h30, Room 1

This debate on the final day of Euroanaesthesia will have experts either for or against opioid-free anaesthesia (OFA). Arguing in favour are Professor Patricia Lavand’homme (Department of Anesthesiology and Acute Pain Service, Cliniques Universitaires St Luc, University Catholic of Louvain Brussels, Belgium) and Dr Jean-Pierre Estebe (Department of Anaesthesiology, University Hospital Rennes; France).

Prof Lavand’homme says: “Anaesthesiologists are committed to provide adequate perioperative analgesia and to support rapid recovery for the patients. Opioids have been used for decades as the corner stone of perioperative analgesia but are now considered as a significant cause of problems at individual level (delayed recovery and poorer outcome) and social level (prolonged use after surgery and gateway to addiction). “

Today, opioids remain the most comfortable choice while OFA (and also “opioid low dose anaesthesia”) is a challenge. Indeed, OFA application is based on the use of different analgesic and antihyperalgesic drug combinations and techniques.

Prof Lavand’homme will explain that OFA requires individualisation of perioperative treatments. She says: “OFA might be considered as application of the science of the anaesthesia, and it matches current concepts of modern perioperative medicine.”

Dr Estebe says that OFA is a multimodal approach combining molecules with pleiotropic effects. He will explain in detail some possibilities for OFA, including the use of lidocaine, ketamine, dexmedetomidine, dexamethasone, propofol and volatile anaesthesia. He will discuss how amitriptyline, magnesium sulfate, and beta blockers can also be used.

He says: “Postoperative pain treatment must be integrated into a program of enhanced recovery after surgery. It should be started perioperatively with a regular multimodal pain approach; prolonged in the post-anaesthesia care unit, with, if necessary, morphine titration (2mg/bolus), and/or amitriptyline; and then in the ward we should promote the oral analgesia route.”

Dr Philipp Lirk, (attending anaesthesiologist at Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA) will deliver the argument against OFA.

“When following the literature on acute postoperative pain management the most unpopular class of drugs is opiates,” says Dr Lirk. “Nevertheless they are used for virtually every type of surgery all around the world. The aim of this lecture is to look critically at the evidence implicating opiates in the transition from acute to chronic pain, side-effects as compared to alternative techniques, the role of opioids in perioperative care of cancer patients, and economic aspects of opioid use.”

He adds: “While judicious use and procedure- and patient-specific administration of opioids or alternative analgesia should be prioritised, my prediction is that opioid-free analgesia will not replace current methods of perioperative management on a large scale. Limit opioids – yes, but ban opioids – no.”