What is opioid-free anesthesia?
For thousands of years, morphine and other opioids have been used by clinicians to manage pain, and these drugs continue to play a key role in anesthesia today. However, most surgical procedures utilize a method called balanced anesthesia, which combines opioids with other drugs that induce sleep and relax muscles. While opioids are effective for pain control, they can cause undesirable side effects, such as serious cardiac and respiratory issues, nausea, vomiting, and digestive complications.
Rising concerns over these adverse effects, along with the ongoing opioid crisis, have led to the development of opioid-free anesthesia. This innovative approach employs non-opioid medications to manage pain before, during, and after surgery, aiming to reduce both side effects and the risk of dependency. Research has demonstrated that opioid-free anesthesia can provide pain relief comparable to traditional opioid-based methods.
Opioid-free anesthesia typically follows a multimodal approach, which targets multiple pain receptors throughout the body rather than relying solely on opioid receptors in the spinal cord. The goal is to block or modulate pain signals coming from the brain, spinal cord, and peripheral nerves, providing effective pain relief while minimizing reliance on opioids.
For example, nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen work by inhibiting COX enzymes, which are responsible for promoting inflammation. Similarly, acetaminophen (Tylenol) also targets COX enzymes. While both of these drugs primarily address pain at the surgical site, their effects can extend to the spinal cord with prolonged use, helping to reduce pain more broadly.
Gabapentinoids, including gabapentin and pregabalin, target specific proteins to reduce nerve signal transmission. These drugs help alleviate neuropathic pain by decreasing inflammation within the nerves.
Ketamine, an anesthetic drug, disrupts pain pathways involved in central sensitization—a condition where the nervous system becomes hypersensitive to pain. This can cause normal sensations, such as light touch, to be perceived as painful, and it can intensify the sensation of existing pain. Ketamine reduces pain sensitivity, which can help lower the risk of developing chronic pain.
Regional anesthesia, which involves injecting local anesthetics near nerves, is another technique in opioid-free anesthesia. This method blocks pain signals from reaching the brain, allowing patients to remain awake but pain-free in the numbed area, thereby reducing the need for general anesthesia and its associated side effects.
By activating different pain pathways simultaneously, multimodal approaches to pain management work synergistically to enhance overall pain relief while minimizing the use of opioids.
In 2022, opioids were responsible for nearly 76% of all overdose fatalities in the United States. At the same time, over 2.5 million American adults were living with opioid use disorder, highlighting the ongoing public health crisis.
Surgery is often the first time patients are prescribed opioids, and their widespread use raises concerns about the potential for long-term use. Some patients, even when opioids are prescribed appropriately for pain management, are hesitant to use them due to fears of dependence and possible side effects. Additionally, leftover pills from these prescriptions can be misused.
To address these issues, researchers like us are working to create a personalized, opioid-free surgical experience. Our approach focuses on both physical and emotional well-being, using effective anesthesia and complementary pain-management techniques to eliminate the need for opioids.
Psychology of pain perception
A patient’s perception of pain is heavily influenced by psychological factors. Research reveals that conditions like anxiety, depression, and sleep disorders can intensify pain by as much as 50%. Therefore, managing mood and sleep-related issues is vital for effective pain relief and enhancing overall well-being.
The perception of pain can be heightened by psychological states due to their significant impact on neural pathways involved in pain processing. For example, stress and anxiety activate the fight-or-flight response, releasing stress hormones that increase nerve sensitivity and intensify pain sensations. Studies also indicate that patients with higher anxiety levels prior to surgery tend to require more anesthesia during the procedure and consume more opioids afterward.
Complementary and alternative therapies targeting psychological factors can alleviate pain and reduce opioid consumption by modulating pain transmission in the nervous system and activating neurochemical pathways that promote pain relief. These approaches include acupuncture, hypnosis, massage, mindfulness meditation, music-based interventions, spinal manipulation, tai chi, qigong, and yoga, all of which have been shown to help manage various painful conditions.
Aromatherapy involves the use of essential oils to stimulate the olfactory system, evoking emotional responses and encouraging relaxation. This process can enhance overall well-being and help diminish the perception of pain.
Similarly, music therapy engages the auditory system, providing a distraction from pain while reducing anxiety and promoting emotional healing. This combination of effects can contribute to a noticeable decrease in pain perception.
Deep breathing and progressive muscle relaxation are effective techniques for activating the parasympathetic nervous system, which encourages a state of rest and relaxation. This activation helps the body conserve energy, reduce heart rate, lower blood pressure, and ease muscle tension. By fostering a calm state, these relaxation exercises can also reduce sensitivity to pain.
Acupuncture involves the insertion of thin needles at specific points on the body to stimulate the release of endorphins and other neurotransmitters. These chemicals help disrupt pain signals and support the body’s natural healing processes.
opioid-free surgery
Shifting away from opioid use in surgical care requires a comprehensive change in both approach and mindset across the entire healthcare team. While anesthesiologists play a central role, other providers, such as surgeons, nurses, and medical trainees, also rely on opioids in patient care. For a successful transition, all team members must embrace alternative pain management strategies throughout the surgical process.
To meet the growing demand for opioid-free surgical care, our team at the University of Pittsburgh Medical Center introduced the patient-initiated Opioid-Free Surgical Pain Management Program in May 2024. This initiative focuses on addressing both the physical and emotional aspects of pain while prioritizing recovery and safety. To achieve these goals, we brought together a multidisciplinary team of surgeons, anesthesiologists, nurses, pharmacists, and hospital administrators.
During a six-month period, our team enrolled 109 patients in the program, with 79 successfully completing surgeries without the use of opioids. Participation barriers included patients’ concerns about severe pain, insufficient preoperative management of stress and anxiety, and a lack of departmental education regarding the program.
Refinements to the program, such as administering muscle relaxants during recovery from anesthesia, increased participation and further reduced opioid use. Notably, none of the 19 patients who received opioids during their hospital recovery required additional opioid prescriptions at discharge.
These results demonstrate the potential of our approach to reduce opioid reliance while still ensuring effective pain management. By strengthening psychological support for patients and providing better education for providers in surgical departments, we can enhance the overall effectiveness of a comprehensive pain management strategy.
