The Arm-Wrestle Over Opioids in the Operating Room

Yves here. While the plural of anecdote is not data, I am very much bothered by the very strong “one size fits all” bias of this article, which was originally titled, “Why opting out of opioids can be dangerous in the operating room.”

The authors take the position that patients must be rendered unconscious for procedures. That is abjectly false. The overwhelming majority of patients no doubt prefer that but it wildly misleading to assert that it is always necessary, unless the real objective is to have the patient unable to hear and recall what the surgical team says while they are working.

I have had two procedures in the last year. One was a bilateral hip replacement at the premier orthopedic hospital in the US, New York City’s Hospital for Special Surgery. They pioneered doing hip replacements with epidurals rather than general anesthesia. That is now standard since recovery times and surgical outcomes are better. Epidurals use mainly or entirely local anesthetics like bupivacaine, chloroprocaine, or lidocaine. Most patients want twilight sleep with that but the hospital has a few weirdos every year like me who want to stay awake and they are fine with that.

For a much less dramatic invervention, a D&C, I had to shop for a surgeon who was willing to do it with local only (this procedure can often be done in office, but the surgeon tried and was unable to do so, so we had to reschedule for at outpatient clinic to get access to heavier-duty equipment, which meant she and I were hostage to hospital bureaucracy). The surgeon was confident I’d be fine (and I was) but the anesthesiologist worked on me hard, even right before the procedure, to get me to have twilight sleep, which I refused. Frankly, I would have been very anxious about the prospect of having someone operate on me when I was knocked out (it seems like rape) while I wasn’t nervous before any of my procedures.

As you’ll see, this article argues that patients making blanket opt-outs of opioids, which a small number of states allow, is a bad idea.  But aside from my distaste for being over-medicated, an entirely separate issue is that opioids do almost nothing to reduce my pain and they make me feel terrible.  So why should I take them when they don’t work and have bad side effects?

But this is separate and apart from my view that anesthesiologists want patients heavily sedated because they are less trouble that way, and thanks to pulse oximeters, anesthesiologists can safely sedate patients more heavily than in the past.

By Mark C. Bicket, Co-Director, Opioid Prescribing Engagement Network and Assistant Professor, University of Michigan; Jennifer Waljee, Associate Professor of Plastic and Reconstructive Surgery, University of Michigan and Paul Edward Hilliard, Clinical Associate Professor of Anesthesiology, University of Michigan. Originally published at The Conversation

Currently, patients in seven states can tell their physicians they don’t want to be treated with opioids in any health care setting, even during surgery. While unnecessary opioid exposure is a big reason behind the opioid epidemic in the U.S., we believe that non-opioid directives that allow patients to opt out of opioids in the operating room may lead to unexpected harms.

Non-opioid directives share some common features with advance directives, legally recognized documents that allow patients to list their preferences for what happens at the end of life. Both documents guide care based on the desires of the patient. Non-opioid directives are mandates that a patient must not receive opioids under any circumstances. Exceptions are rare.

Congress is currently considering legislation allowing access to these directives across the nation. While only one of the seven states with non-opioid directives excludes care during surgical procedures, both proposed bills in the House and Senate contain an exclusion specific to care in the operating room.

We are a team of physicians who work with and study the use of opioids in surgical settings. Two of us co-direct the Opioid Prescribing Engagement Network, which develops best practices for opioid prescriptions after surgery. We have seen medical practice shift from embracing opioids to eliminating them altogether. We believe that opioids serve an essential tool in the operating room for many patients, and avoiding them for certain cases can make it difficult if not impossible to avoid harming patients.

The Role of Opioids in Anesthesia

Anesthesia is tailored for each patient depending on the surgical procedure, with the appropriate degree of sedation varying for each case. At one end of the scale is minimal sedation, which usually allows patients to respond to verbal commands. At the other end is general anesthesia, which keeps patients unconscious even during pain. Different medications make this range of sedation possible.

A concept called balanced anesthesia has guided clinicians in how they care for patients in the operating room for more than a century. The goal is to give a patient different types of medications to obtain loss of pain, memory, movement and consciousness while preserving other essential functions of the body.

Relying on only one or two types of medication usually requires higher doses to achieve anesthesia, which can result in bothersome or concerning side effects. Using a combination of drugs, on the other hand, lowers the amount of drug needed to achieve sedation. Because each drug works on a different set of receptors in the body, the desired effects can be attained with smaller doses of each drug than with one drug given alone. This reduces the risk of side effects and leads to more stable vital signs during surgery.

Opioids stand out among the typical sedatives and anesthetics used in the operating room by significantly reducing the amount of other drugs needed to achieve pain relief, sedation and loss of consciousness. Even small doses of opioids are sufficient to activate areas in the brain that decrease the input of pain signals from other areas of the body.

Why the Operating Room Is Different

As broader calls to reduce unnecessary opioid use rise, anesthesiology and surgery researchers have asked whether avoiding all opioids in the operating room would lead to better patient outcomes. The first set of published studies on this question suggests that completely eliminating opioids from the operating room may do more harm than good.

In one study, researchers randomly assigned patients who needed general anesthesia for surgery to either a group that received an ultrafast-acting opioid or a non-opioid sedative commonly used in intensive care units. After a surprising number of patients in the non-opioid group experienced serious adverse events during surgery, such as dangerously reduced heart rates and low oxygen blood concentration, the researchers stopped the study early because of safety concerns.

Similarly, a review of studies found that eliminating opioids during surgery did not decrease either patient use of prescription opioids after discharge or provider overprescription of opioids beyond just reducing opioid dosage during the procedure.

Non-Opioid Directives and the OR

Drug overdoses in the United States continue to reach record numbers, with estimates of more than 107,000 deaths in 2021. How best to use pharmaceutical company lawsuit settlement payouts given to West Virginia and other states has been hotly debated. But we believe that approaches that allow patient to opt out of opioids in the operating room may lead to unsafe care.

Opioids are useful beyond pain reduction and play a role in helping patients safely emerge from general anesthesia. Avoiding opioids may be a safe option when general anesthesia is not needed, such as procedures on the hand, leg or feet that use only nerve blocks to reduce pain. Prescription opioids may also not be needed when patients recover at home after many types of surgery.

Opioids are a tool that can complement a thoughtful anesthetic and surgical plan. Whether or not patients receive opioids during surgery doesn’t affect how likely they are to continue using opioids or receive an opioid prescription afterward. We believe that wholesale elimination of opioids without considering the unique setting of the operating room may lead to unintended safety risks for patients. A more nuanced care plan that relies on reduced amounts of opioids could set patients up for a faster recovery with fewer side effects and better outcomes after surgery.

Print Friendly, PDF & Email


  1. Juneau

    I have noticed cognitive issues for weeks after general anesthesia and it is a real problem. I think another reason surgeons like general anesthesia is that it allows for paralytics which keep patients from moving while they are open and with instruments inside, or even jumping/falling off of the surgical table during the procedure. Also the intubation protects the airway and prevents aspiration of stomach contents to some degree (which can cause pneumonia). I don’t have a strong opinion on this but wonder if someone more familiar with this area could comment. I would love to avoid general anesthesia again.

    1. Yves Smith Post author

      Just so you know, if you are ever in this position again, twilight sleep does not require intubation and is suppose to have pretty much no cognitive effects (not that I am that trusting!).

      They did finally have to use twilight sleep on me in the hip replacement (when you have an epidural, you can’t move your lower body, but they were having real trouble getting the rest of me in the position they wanted me to be in and I kept shifting enough to make them unhappy). I woke up in the recovery room and immediately started bitching about having been knocked out (I didn’t and still don’t recall what happened).

      The anesthesiologist came to see me in the hospital and apologized! I was really astonished since it seemed like I had been a bit of a bad actor.

  2. The Rev Kev

    I can see the sense in giving people anesthetics based on what is required. A fortnight ago they had to work on my ankle and gave me some stuff called Ketamine. I was awake and followed the conversations but definitely did not feel the pain that would have been going on. It was an interesting experience. Then a week ago they did the real surgery and knocked me out but good which left the surgeons in peace to concentrate on the task at hand. I think that when you send somebody under, there are increased risks which was why I was in a theater at the time. The first time was not necessary so not only did they reduce risks but saved resources as well. In the military that concept is called conservation of force and I think that it applies here as well.

  3. Stick'em

    Anecdote salient to discussion: yesterday at the pool, the mother of one of my daughter’s elementary school aged friends – call her Mabel – told me Mabel is having surgery to remove a rod from her thigh in a few days.

    What happend was the dog’s leash got wrapped around Mabel’s legs. Then dog took off to chase some squirrel or something. The resulting crash broke Mabel’s femur – ouch!

    Mom goes on to say following the surgery to insert the rod, one of Mabel’s lungs basically stopped working, related to the anesthesia. Mom called this “lazy lung,” and says now Mabel uses an albuterol inhaler, as if she has asthma. The medical term for this is atelectasis.

    So I ask mom what kind of anesthesia they are going to use during the rod removal. Is it the same as during the rod insertion (presumably an opiate)? Is it the same anesthesiologist? It became quickly evident mom didn’t know the answers to these questions…

    Mom doesn’t know how to advocate for her daughter. I know because years ago my wife had a reaction to an opiate sedation at the hospital and stopped breathing. There’s a reason opiates such as codeine are used in cough suppressants, right? They act upon the lungs. My wife is much more sensitive to this than the average person for whatever reason.

    And so when my wife was giving birth years later at the same hospital, an anesthesiologist planned on giving her an opiate during delivery. Because said anesthesiologist had what I’d call a god-complex, he refused to admit he’d f’ed up in his plan. Instead, I got the “I’ve been doing this for 40 years, I know what I am doing. You are just a layman.” lecture. That act doesn’t work on me.

    So I got the secretary to dig out the paper chart stored somewhere off site in a cardboard box, which documented the original reaction. It happened to be the same anesthesiologist’s name on the old chart. So I pitched a fit until we got assigned a different anesthesiologist. Sometimes you gotta kill god and get on with living.

    The point being, iatrogenic problems are a thing. Advocating for yourself in a hospital is a thing. Don’t be afraid to say something. You may be right and you may be wrong when you say something, but much better outcome to prevent problems than to hire a lawyer after the fact. Doctors are not gods, contrary to what you might see portrayed on the TeeVee. Ask questions. Take notes. Get someone to go to the hospital with you to act as an observer/advocate.

    “Iatrogenesis is the fifth leading cause of death in the world.”

    1. Yves Smith Post author

      Rod in femur is not all that different that hip replacement (they really drive the spike that goes with the new ball into the femur) except perhaps they’ve so perfected hip replacements that they do a ton with robots so they have much smaller incisions than they used to.

      But having said that, it’s all lower body and it ought to be possible to do like the hip replacement, with an epidural and twilight sleep. It’s a shame that this is so far along she can’t find a surgeon who will do it that way.

    2. Lexx

      I’m allergic to opiates and would like to see such legislation pass in every state.

      I’ve been aware of the allergy and have written under ‘Allergies’ on every medical chart since my teens, ‘opiates and all analogs, penicillin and all analogs’. But physicians don’t seem to read charts, so before a procedure I remind them what’s on my chart and get the same blank expression every time, and some version of ‘well, what can you take?!’. Like I’m in charge and it’s my responsibility to give them guidance as to what their options are! Then I reply, ‘Not opiates, I’m allergic.’ They pounce on the opening, ‘What kind of allergic reaction?’ ‘Itching, like the curse of ‘may the fleas of a thousand camels nest in your crotch’, but my whole body.’ They blink as I confirm it’s not life-threatening (yet) and won’t be their problem. The nurses will get to deal me after the doctor has trotted off home… and he won’t be on call that night… and then he/she proceeds to prescribe an opiate drip anyway.

      Oh, and there’s the IBS I’ve been living with for 64 years. No, the other kind that makes being involuntarily given opiates exponentially worse… and you know that part where they won’t release the patient until there’s some evidence their bowels are moving again?

      I see Colorado isn’t on the list. Would help explain why physicians feel they can just ignore their patient’s wishes. The addicts and the allergics have common cause for similar reasons. Taking opiates is bad for our health. The states that are listed giving patients the legal power to opt-out did so because they’re being overwhelmed with the costs of addiction in their states, not because they give a rat’s ass about the pain and destruction of patient’s lives, or the ‘inconvenience’ of side-effects. They’re legally allowed to act in their own best interests and they get to decide what ‘do no harm’ means?

      My advocate is usually my husband and he’s hopeless in that role. Next time I’m going to ask him to sneak in a disposable enema so we can get the hell out of there faster.

  4. orlbucfan

    Man, I hope this isn’t a signal that they’re adding crap like fentanyl to standard operating anesthesia. I wouldn’t doubt it with the corrupt Deathcare System.

    1. Jokerstein

      Fentanyl is not at all uncommon in anaesthesia: for my colonoscopy I was offered fentanyl and midazolam. I went with nothing at all because I wanted to see the movie! Very uncomfortable, but a great show…

  5. Raymond Sim

    I believe an item in Links recently made reference to the fact that we don’t really understand how general anesthetics work.

    Personally I react very badly to nitrous oxide, becoming paranoid and potentially violent. I once began to return to reality, a place where it turned out I was not in fact being persecuted by crazed sadists, to find that four women were not very successfully attempting to restrain my arms and legs, while our family dentist seemingly knelt on my chest. I got an arm free, and tried to rid myself of him, but couldn’t, because he was holding onto one of my teeth with a pair of pliers, which when I came to think of it, was his job, and why I was there.

    I later learned, from an episode of NOVA I think it was, that a similar incident marred one of the early demonstrations of nitrous oxide anesthesia in the U.S., nonetheless I’ve never encountered any awareness of this as a ‘real’ phenomenon in medical or dental personnel, and I have to content myself with convincing them I’m some sort of crank whose fear of nitrous should be indulged.

  6. Mikerw0

    I am completely with you. I have had multiple surgeries and not once had opioids. Some other factors to consider. Opioids affect motility and tend to lengthen hospital stays. Our daughter has had a dozen surgeries due to Crohns and not once had opioids, this includes a grueling, and very complicated, colectomy. Her surgeries were at NY Presbyterian Cornell, with the colectomy performed by the hospital’s Chief Surgeon. They even commented to us on other surgeons using opioids in colorectal surgeries due to the impact on recovery.

    I recently had wrist surgery for a dislocation and the main topic of conversation was that I did not want post-op opioids. Both the surgeon and my physician agreed just stay ahead of the pain with ibuprofen and I would have no issues. Funny thing, that worked great. Again, the surgeon questioned the laziness of many docs going for opioids when they really aren’t needed.

    [Of course the crime was taking a painkiller designed for end of life pain management, e.g., cancers, and turning it into candy for the masses.]

  7. Rick

    Having a family history of colon cancer and having polyps, I’ve had a number of colonoscopies. I don’t mind the opioid (fentanyl) being used but really dislike the sedative (propofol or midazolam) they like to push. I found a doctor who didn’t mind going without the sedative but he moved away so I had to go to a new doctor for my recent colonoscopy. Turns out this doc was also fine with analgesics only but the young nurse anesthetist kept badgering me about my choice which was pretty annoying.

    I had midazolam for the first one years ago and it was a very bad experience. Left me seriously agitated for several days and with tinnitus for a month.

    There’s a doctor (Wes Ely, @WesElyMD) who has waged a long campaign against the automatic use of sedatives, especially for patients in the ICU. He claims better outcomes like less dementia and post intensive care syndrome.

    1. curlydan

      I had a bone marrow biopsy about 10 years ago and had a similar experience with the nurse. She thought I was totally crazy to not get knocked out during the procedure. I guess I was the only one who asked to do that. The doctor was totally fine with it.

      The weird part was that they still rolled me into post-op with all the knocked out patients and made me wait there an hour. So I just stared at the zombified patients around me and kind of twiddled my thumbs.

  8. Elizabeth

    Several years ago I had a lumpectomy. At the time I was being treated for pneumonia. The anesthesiologist came in before surgery and I told him I didn’t want any heavy sedation because of that, and he didn’t give me a hard time. I was in a twilight sleep, but was mostly awake. I could hear the surgeon and others in the OR, and could feel them digging around in me. It wasn’t that bad, and after the surgery they gave me tylenol (which does nothing for me). I have a high threshold for pain.

    When I was in my 20s I had a serious surgery and afterwards I was on mophine for 3 days, then cut off. General anesthesia has risk, but I think taking opioids (for someone who doesn’t know how they’ll react is also risky.

    Honestly, I didn’t know docs were pushing opiods. Not for me.

    1. ambrit

      The “Pain Management Specialists” were pushing opoids too. After the amputation, the Medicos gave Phyl oxycontin for the “pain.” (She had more problems with phantom pains than real ones.) She quite quickly weaned herself off of the drug. Three months after the surgery, the Nurse doing the actual “face time” with the patients, in loco medico, suggested that Phyl increase the dose.
      “Don’t you want to keep on top of the pain?” asked the nurse.
      “I am already ‘on top of it,” was Phyl’s reply.
      “But you’re still at the low end of the dosage scale,” was the return sally.
      “Um, I’m almost off of the stuff now,” Phyl replied, “Why would I want to increase the dose? I want to get off of it.”
      The puzzlement evident on the nurse’s face was good for a laugh.
      But, yes, much of the medical establishment does indeed ‘push’ pain killers.

  9. ghiggler

    I agree with Yves that ‘“one size fits all” bias’ is real and so very wrong.

    And “While the plural of anecdote is not data,” I would argue that anecdotes, when marshalled against “one size fits all” are, in fact, data. They cannot confirm, but they can help disconfirm a premise. So, to date in this discussion:

    Juneau I have noticed cognitive issues for weeks after general anesthesia and it is a real problem
    Mom via Stick’em one of Mabel’s lungs basically stopped working, related to the anesthesia
    Stick’em years ago my wife had a reaction to an opiate sedation at the hospital and stopped breathing
    Lexx I’m allergic to opiates
    Raymond Sim … we don’t really understand how general anesthetics work. Personally I react very badly to nitrous oxide, becoming paranoid and potentially violent
    Rick I don’t mind the opioid (fentanyl) being used but really dislike the sedative (propofol or midazolam)… [Midazolam] was a very bad experience. Left me seriously agitated for several days and with tinnitus for a month

    In my mother’s later years I always noted to doctors not to prescribe codeine. Even after just one dose she became greatly confused for about a week. This always led to a recurrent strong recommendation that she enter long term care. Yes, she was suffering from long-term cognitive decline, but the iatrogenic codeine crises was short term. In her own “assisted living” apartment she was fine for years.

    I once mentioned to my supervisor that I had taken Robax muscle relaxant for a multi-day foot cramp while skiing. She was horrified and clearly questioned my sanity, to some extent my fitness to think clearly in my job. Neither I nor my family noticed any difficulty with my downhill skills. Clearly, she had had quite different experiences.

    A cousin has been living with chronic back pain for almost twenty years. When talking with him during the times he was on the stronger and more addictive drugs he was slower, became repetitive, brought up injuries and insults from years before, found fault with people and things around. Strangely enough, he recently broke both legs in a fall and cut back on the pain meds for his back. In conversations now he is clear, plans well, understands indirect points in our conversations, demonstrates the odd sense of humor that I enjoy. It’s been a lot more fun to have our phone conversations. If he was addicted to some of the stronger drugs, he shows no sign of it now.

    I guess I’ll have to score some opioids for a test. Will they act on me weakly, like the Robax, or like my cousin with some confusion but no addiction, or like my mother, with full confusion. It would be better to be clear on that ahead of time so as to be able to give evidence-based directions for any treatments I may need.

    And so I reiterate the point made in many of the comments above. Take part and advocate in your own treatment, advocate for those near and dear to you when they cannot. Doctors are not gods, and they need to explain what they want to do and should be able to explain clearly why.

    That said, I accept that doctors make mistakes. Obviously, it’s a step too far if they cut off my right foot when the left was to be removed, but I am probably more forgiving than most. It’s not acceptance of holy infallibility, but acceptance of human failings.

    Speaking specifically to the article, I appreciate one of the important points, “desired effects can be attained with smaller doses of each drug than with one drug given alone.” I want the clearly defined desired effects to be achieved. I certainly don’t want to be conscious but immobile while someone roots around in my innards. I don’t want to jump off the operating table while someone is sewing up my aorta.

    But I do want to understand ahead of time what will be going on and will expect my doctor to make my experience and knowledge part of the plan.

  10. Sue inSoCal

    Good points all round. Everyone is different, our bodies are individual and we react differently to medications. Because of a cochlear implant, I need to be “under” for an MRI. I’ve asked repeatedly if they can just do this with versed/twilight sleep. But no. The last time (4 yrs) I had one, they pushed propofol with no premedication. I was awake and paralyzed with the lidocaine that hit my veins scalding, hearing staff say “stay with us;” I was only able to move my eyes. I should have more frequent MRIs, but I’m done fer after that. I’ve also had, what I consider at my advanced age, my last necessary surgery. What someone said about being foggy after isn’t kidding; it took me a few weeks to realize what a butcher the surgeon was (removal of mastectomy prostheses). I didn’t even realize how awful it was right away. As for the person who lists a medication(s) as allergic, forget it. Most don’t even read it. I have latex anaphylaxis, there were warnings everywhere. Nonetheless, these people almost killed me wrapping me in a latex compression bandage after the hack job. No more surgical adventures for me. I shall try to be careful….

  11. VT Digger

    Right before my endoscopy last year I asked the nurse offhand what they were going to use for my conscious sedation.

    “Oh, just a little Fentanyl.”

    I immediately requested they use Ativan which is FAR safer and just as effective for purpose. Nurse just shrugged and said
    “Sure. Whatever you want.”
    Absolutely insane that a morphine equivalent is the default nowadays. Do they not know this is exactly how people end up dependent? Is that the plan?

    This was at Dartmouth, not some podunk facility.

  12. hoonose

    A dose of fentanyl to induce anesthesia is not going to make you opioid dependent! My last surgery was a laparoscopic gallbladder in 2015, and it worked fine. If anyone is worried, and as a retired internist I am not, ask for Propofol. It is amazing!

    1. Sue inSoCal

      I would agree. What I don’t buy is the “you took an opiate, you’re hooked forever”. If that were the case, I’d be a morphine fiend prowling the streets. I agree with Yves: I don’t like any “one size fits all”. Everyone has different pain tolerances and processes medications differently. You’d likely know more about that than I would!

      1. johnnyme

        I think that’s a big part of the issue — everyone processes medications differently. Opioids do their intended job admirably without any issues for some people (I appear to be one of them, thankfully) and lead to a hellish downward spiral for others and there’s no way to know ahead of time which path they’ll take you down.

        I had surgery a few years ago to reconstruct a badly shattered clavicle and being told I was going to be given fentanyl was by far the most nerve-wracking aspect of the procedure (for both me and my sister who accompanied me to the surgery). Had I known I could have potentially requested an alternative, I absolutely would have. So I just ended up rolling the dice and hoping for the best…

        I declined a prescription for opioids in the emergency room after the accident (the response I got from the attending staff was, “we like that answer”) and skipped the percoset they prescribed me afterwards. There was a study linked here at NC a few years ago (I searched but can’t find the original links or water cooler page) that showed no statistical difference in outcomes between opioids versus a combination of ibuprofen + acetaminophen for several different kinds of pain so it was OTC meds for me all the way and that bullet was successfully dodged.

    2. Yves Smith Post author

      Did you read my intro or the comments? No one raised an issue about addiction.

      First, opiates do mess with your brain. Total anesthesia is implicated with cognitive decline.

      Second, in my case, they do NOT reduce pain at normal doses (which suggests I’d need a higher than normal dose to knock me out) and they make me feel terrible. Why should I be subjected to them?

      And see this from a recent paper.

      This narrative review will consider current understanding of the reasons that elderly patients need enhanced care, and recommendations for that care based on established and recent empirical research. In that latter regard, unless and until we are able to classify anesthetic neurotoxicity as a rare complication, the first-do-no-harm approach should: (1) add anesthesia to surgical intervention on the physiological cost side of the cost/benefit ratio when making decisions about whether and when to proceed with surgery; (2) minimize anesthetic depth and periods of electroencephalographic suppression; (3) limit the duration of continuous anesthesia whenever possible; (4) consider the possibility that regional anesthesia with deep sedation may be as neurotoxic as general anesthesia; and (5) when feasible, use regional anesthesia with light or no sedation.

      #5 is what HSS does for everyone for hip and knee replacements, and they get better recovery times and surgical results.

      If this is an issue for the elderly, it could also be problematic for younger people who have repeated procedures. And you can’t anticipate that in advance.

      My beef with this article (and I did not read their linked JAMA paper, this piece is written to be stand-alone) is their argument for opioids was based on the presumed necessity of knocking patients out fully. That isn’t desirable if lesser sedation is viable. Their implicit standard is anesthesia overkill.

  13. Dugless

    In terms of full disclosure, I am an anesthesiologist at a large academic medical center and also have had pretty much every type of anesthesia one can have (both general anesthesia, sedation and regional anesthesia). There are many points of discussion that may warrant further discussion based both on this article and some of the comments but I want to try to limit my comments to the specific points about the need for opioids during anesthesia made by the authors of the article (only one of whom actually appears to be an anesthesiologist).

    The first point that opioids are necessary to conduct a “balanced anesthetic” is patently false. It is true that there is some synergistic effect of opioids on other anesthetic agents but this is hardly necessary to conduct a quality anesthetic. As was pointed out, one size does not fit all and I occasionally use intra-operative opioids but this is rare. I strive to limit opioid exposure in the perioperative period as do most of my colleagues. I doubt there is one person that I work with that would not honor a patient request to not use opioid medication during surgery. The times I have had surgery, I specifically requested no opioids and my colleagues were more than happy to honor this request and I had no ill effects from a non-opioid based anesthetic.

    Second, the authors point out two studies to support their contention that opiates are necessary in the operating room. So let’s talk about the literature on intra-operative opioids. The first study that was cited was, in my opinion, not only a poorly designed study but didn’t even show that opioids were useful. The study was stopped due to significant bradycardia (slow heart rate) in the non-opioid group who received a sedative medication called dexmedetomidine instead of an opioid. This is a known side effect of dexmedetomidine and they were likely overdosing the patients. I use this medication all the time and have never had problematic bradycardia because I dose it judiciously. And here are the results from the abstract: “Cumulative 0 to 48 h postoperative morphine consumption (11 mg [5 to 21] versus 6 mg [0 to 17]) and postoperative nausea and vomiting (58 of 157 [37%] versus 37 of 157 [24%]; relative risk, 0.64; 95% CI, 0.45 to 0.90) were both less in the dexmedetomidine group”. So the group that did not get opioids used LESS morphine for pain relief after the surgery and had LESS post-operative nausea and vomiting both of were statistically significant. Hardly a ringing endorsement for an opioid-based anesthetic. It is well known (or at least should be) that the use of intra-operative opioids have significant side effects including causing hyperalgesia (the phenomenon of increasing pain which is likely why the patients that received opioids during the surgery required MORE opioids after surgery) and post-operative nausea and vomiting/constipation. There are also probably other more subtle effects on immune response that need further research. If you would like to see a study (from 2007! and also published in Anesthe) that indicates that a non-opioid approach produces better results, see this link: There is plenty more evidence to support this.

    The second article cited just purports to show that using intra-operative opioids does not lead to abuse. I am happy to concede this point but as noted above, intra-operative opioids leads to more post op opioids and likely more use of out of hospital opioids. The path to abuse is clearly complex but we do know that some percentage of surgical patients started on opioids end up addicted so we should avoid them as much as possible.

    Finally, I think most anesthesia providers at this point are aware that we should limit opioid exposure. Unfortunately, pain is a huge problem that does not have easy solutions or necessarily good treatments so the use of opioids will likely continue. However, I think the pro opioid forces are steadily losing the argument (kind of the like the neoliberals). Happy to try to answer any questions if I can.

    1. Yves Smith Post author

      I very much appreciate you taking the trouble to write such a detailed comment and to challenge the studies the authors relied on. This may be helpful to other readers who might have to challenge anesthesiologists who are still using older protocols (I haven’t had anything done here in the South but my strong impression is that they are conservative, as in tend to stick to older practices).

Comments are closed.