Session O8D1: Opioid free anaesthesia: pro-con debate

Session O8D1: Opioid free anaesthesia: pro-con debate

Saturday 2 June, 11h00-12h00, Green Room

In this session, Dr. Patricia Lavand’homme and Dr. Philipp Lirk will critically reflect on the evidence-base for opioid-free anaesthesia (OFA) in perioperative medicine.

Opioids have been used for pain relief for millennia and have contributed to improve the quality of life of countless number of patients enduring severe postoperative pain and cancer.   Over the past two decades, there has been a trend to prescribe opioids also for benign pain syndromes, and for increasing periods of time postoperatively.

Thus, use of opioids throughout anaesthesia and pain medicine expanded, but in parallel, a considerable body of evidence has emerged implicating opioids in a wide variety of negative scenarios from more or less dangerous adverse effects (nausea and vomiting, delirium, respiratory depression) in the immediate perioperative period, to long-term opioid dependency of patients, and potentially even an increased risk of tumour recurrence. In addition, too many patients remain on opioid prescriptions postoperatively both in United States (contributing to the observed “opioid crisis”) and in Europe.

In this context, the concept of OFA has gained in popularity. Whether or not early “opioid-based anaesthesia” has been permitted to manage fragile patients because it provided haemodynamic stability, the negative impact of opioid-related side effects on patient’s recovery has prompted the development of “balanced anesthesia” where a combination of synthetic opioids and non-opioid analgesic drugs is used to improve surgical outcome.  OFA moves a step beyond this: why do (we think that) we need intraoperative opioids?

Professor Lavand’homme (Catholic University of Louvain, Brussels, Belgium) will present the scientific argument in favour of OFA.  She says: “Today, non-opioid drugs may help to blunt the stress response and to promote intraoperative haemodynamic stability.  Further, the administration of opioids to control intraoperative ‘pain’ — by definition, a conscious experience — deserves some discussion because in anaesthetised patients, the term ‘nociception’ is more appropriate.”

As the goal is to spare opioids for postoperative analgesia, Dr Lavand’homme will discuss expected benefits of OFA on postoperative recovery, particularly how it may help to manage postoperative pain.  She says: “Finally, questions and future challenges will be presented such as the need for procedure-specific strategies, the lack of accurate tools to monitor intraoperative nociception and the missing objective assessment on patient outcome.”

Dr. Lirk (Brigham and Women’s Hospital and Associate Professor, Harvard Medical School, Boston, MA, USA) has been asked to provide the scientific counter-argument, and he will try to critically reflect on the literature surrounding perioperative use of opioids. In particular, he will focus on the clinical relevance of opioid-induced hyperalgesia, the ease or difficulty of treatment of side-effects, the evidence concerning the relationship between opioids and tumour recurrence, the issue of diversion and addiction, and a brief glimpse at potentially novel opioids with improved side effect profiles.

“Lastly, I will try to make the case that while reducing opioids during surgery is probably a noble goal in itself, the period following surgery, on the ward and after discharge, is the time when things can go utterly wrong and liberal prescription practices for opioids after surgery may be more important in leading to patients on sustained opioid medication than a few milligrams of morphine in the operating room.”

His conclusion will be that while reducing opioids is always a good idea, we should not consider moving towards opioid free anaesthesia just yet.