Opioid-free Anesthesia: Reply

We thank Forget et al.¹  and Ingrande and Drummond²  for their interest in our review on perioperative opioid administration.³  Forget et al. contend that we did not distinguish between opioid-free anesthesia and opioid-free analgesia and ignored published studies and a meta-analysis.⁴  On the contrary, we explicitly distinguish between these two phases of care and even abbreviate them, so as to clarify our position throughout. Unfortunately, the definition of opioid-free anesthesia in literature seems to be loosely applied and consequentially misinterpreted. Whether opioid-free anesthesia means total abstinence or relative lack of intraoperative opioids is unclear. We discuss this as an important limitation of the review and meta-analysis by Frauenknecht et al.,⁴  in which included studies used opioids during the intraoperative period, thereby resulting in a potentially inappropriate conclusion.⁵  Furthermore, our statement that total avoidance of perioperative opioids has no influence on the long-term outcomes is based on evidence,^6–8  contrary to the statement made by Forget et al.¹  The most fundamental question is whether the goal of total opioid avoidance is really necessary and at what cost.

Ingrande and Drummond²  draw attention to the fact that use of combination of medications (polypharmacy) is hazardous, which is indeed true. However, with regard to multimodal analgesia, we differ from their broad interpretation. The original definition of multimodal analgesia clarifies that the goal was to achieve sufficient analgesia due to synergistic effects between different group of analgesics, with accompanying reduction of side effects as one would be less dependent on a single analgesic modality.⁹  In our article, we clarify that the choice of what can be included as multimodal needs to be based on (1) intrinsic analgesic potency, (2) opioid-sparing potential, and (3) potential side effects. Bundling all modalities under nonopioid analgesics is inappropriate. We need to distinguish between adjuncts such as gabapentinoids, dexmedetomidine, lidocaine, ketamine, and magnesium versus known analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2–specific inhibitors or loco-regional techniques.¹⁰  In fact, acetaminophen and nonsteroidal anti-inflammatory drugs or cyclooxygenase-2–specific inhibitors should be administered to all surgical patients unless there are contraindications.¹⁰  Moreover, there are procedure-specific and patient-specific considerations, and a one-size-fits-all approach is not recommended. Because avoiding opioids, irrespective of the context, is seen to provide a compelling narrative in the background of the opioid crisis, analgesic practices seem to have resorted to multiple combinations of untested agents, overzealous application of drug combinations, or multiple interventions leading to toxicity and patient harms.^11,12  We highlight the need for more balanced and responsible decision-making.

Dr. Joshi has received honoraria from Baxter International Inc (Deerfield, Illinois) and Pacira Bioscience Inc (Parsippany, New Jersey). The other authors declare no competing interests.