Impact of Opioid-Free Anesthesia on Analgesia and Recovery Following Bariatric Surgery: a Meta-Analysis of Randomized Controlled Studies

This meta-analysis aimed at exploring the impact of opioid-free anesthesia (OFA) on pain score and opioid consumption in patients undergoing bariatric surgery (BS). Literature search identified eight eligible trials. Forest plot revealed a significantly lower pain score (mean difference (MD) =  - 0.96, p = 0.0002; 318 patients), but not morphine consumption (MD =  - 5.85 mg, p = 0.1; 318 patients) at postoperative 24 h in patients with OFA than in those without. Pooled analysis also showed a lower pain score (p = 0.002), morphine consumption (p = 0.0003) in the postanesthetic care unit, and risk of postoperative nausea/vomiting (p = 0.0003) in the OFA group compared to the controls. In conclusion, this meta-analysis demonstrated that opioid-free anesthesia improved pain outcomes immediately and at 24 h after surgery without a beneficial impact on opioid consumption at postoperative 24 h. KEY POINTS: • Roles of opioid-free anesthesia (OFA) in bariatric surgery (BS) were investigated. • Outcomes included postoperative pain score, opioid use, and nausea/vomiting risk. • OFA was associated with lower 24-h pain score but not opioid consumption. • Lower pain score and opioid consumption were noted in the postanesthetic care unit. • OFA correlated with a lower risk of postoperative nausea/vomiting.

Opioid-Sparing Perioperative Analgesia Within Enhanced Recovery Programs

Opioid-based analgesia in the perioperative period can provide excellent pain control, but this approach exposes the patient to avoidable side effects and possible harm. Optimal analgesia, an approach that targets the fastest functional recovery with adequate pain control while minimizing side effects, can be achieved with opioid minimization. Many different options for nonopioid multimodal analgesia exist and have been shown to be efficacious, with certain modalities being more beneficial for specific surgeries. This review will present the evidence and practical tips for these management strategies.

Multimodal nonopioid pain protocol provides equivalent pain control versus opioids following arthroscopic shoulder labral surgery: a prospective randomized controlled trial

BACKGROUND

This study aimed to compare postoperative pain and patient satisfaction in patients undergoing primary arthroscopic labral surgery managed with either a nonopioid alternative pain regimen or a traditional opioid pain regimen.

METHODS

Sixty consecutive patients undergoing primary arthroscopic shoulder labral surgery were assessed for participation. In accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement, a prospective randomized controlled trial was performed. The 2 arms of the study were a multimodal nonopioid analgesic protocol as the experimental group and a standard opioid regimen as the control group. The primary outcome was postoperative pain scores (on a visual analog scale [VAS]) for the first 10 days postoperatively. Secondary outcomes included patient satisfaction, patient-reported outcomes, and complications. Randomization was performed with a random number generator, and all data were collected by blinded observers. Patients were not blinded.

RESULTS

Twelve patients did not meet the inclusion criteria or declined to participate. Thus, 48 patients were included in the final analysis: 24 in the nonopioid group and 24 in the opioid group. There was no significant difference in VAS or PROMIS (Patient-Reported Outcomes Measurement Information System) scores between patients in the 2 cohorts on any postoperative day (P > .05). When we controlled for confounding factors with repeated-measures mixed models, the nonopioid cohort reported significantly lower VAS and PROMIS (Patient-Reported Outcomes Measurement Information System) Pain Interference scores (P < .01) at all time points. No difference was found in reported adverse events (constipation, diarrhea, drowsiness, nausea, and upset stomach) between cohorts at any time point (P > .05).

CONCLUSION

This study found that a multimodal nonopioid pain regimen provided, at the minimum, equivalent pain control, an equivalent adverse reaction profile, and equivalent patient satisfaction when compared with a standard opioid-based regimen following arthroscopic shoulder labral surgery.

Protocol for a multicenter randomized controlled trial comparing a non-opioid prescription to the standard of care for pain control following arthroscopic knee and shoulder surgery

Background

Opioids continue to be the analgesic of choice for postoperative pain control following arthroscopic knee and shoulder surgery. Despite their widespread use, there are limited evidence-based clinical practice guidelines for postoperative opioid prescribing. The Non-Opioid Prescriptions after Arthroscopic Surgery in Canada (NO PAin) Trial is a randomized controlled trial (RCT) designed to determine whether a non-opioid analgesia approach to postoperative pain, compared to usual care, reduces oral morphine equivalents (OME) consumed in patients undergoing outpatient knee and shoulder arthroscopy.

Methods

This is a multi-centre, RCT with a target sample size of 200 patients. Adult (18+ years of age) patients undergoing outpatient knee and shoulder arthroscopy will be randomized to a non-opioid postoperative protocol (intervention) or the current standard of care (control). The intervention will consist of a standardized non-opioid analgesic prescription, a limited rescue opioid prescription, and a patient education infographic. The control is defined as the treating surgeons’ pre-trial postoperative analgesic regimen. Exclusion criteria include chronic opioid use, concomitant open surgery, contraindications to the prescribed analgesics or ongoing workers compensation/litigation. The primary outcome is OMEs consumed at 6 weeks postoperatively. Secondary outcomes will include patient-reported pain and satisfaction, quantity of OMEs prescribed, number of opioid refills, and any adverse events up to 6 weeks postoperatively. Utilizing the intention to treat principle for all analyses, independent samples t-test and presented with a p-value as well as a mean difference (MD) with 95% confidence intervals (CIs) will be performed for primary and secondary outcomes.

Discussion

The ongoing opioid epidemic and overprescribing of opioids in orthopaedics serve as the rationale for this trial. There is a lack of evidence upon which to develop post-operative pain management guidelines for patients undergoing arthroscopic surgery. A prospective evaluation of this relatively inexpensive intervention will demonstrate whether an explicit effort to reduce the number of opioids prescribed results in a reduction in the amount of opioids consumed and help to inform future studies and guidelines.

Trial registration

The NO PAin trial has been prospectively registered with clinicaltrials.gov (NCT04566250).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04354-x.

Nonopioid Adjuncts and Alternatives

Multimodality nonopioid analgesia can be effective for pain control. Balancing risks and benefits of treatment should guide the appropriateness of opioid versus nonopioid pain control.

Perioperative Analgesia in Pediatric Patients Undergoing Otolaryngologic Surgery

This article reviews the evidence regarding current perioperative pain management strategies in pediatric patients undergoing otolaryngologic surgery. Pediatric otolaryngology is a broad field with a wide variety of surgical procedures that each requires careful consideration for optimal perioperative pain management. Adequate pain control is vital to ensuring patient safety and achieving successful postoperative care, but many young children are limited in their capacity to communicate their pain experience. Current literature holds a disproportionate amount of focus on pain management for certain procedures, whereas there is a paucity of evidence-based literature informing most other procedures within the field.

Nonsteroidal Antiinflammatory Drugs for Acute and Chronic Pain

Understanding nonsteroidal antiinflammatory drug (NSAID) use and impact on common rheumatic and arthritic conditions is critical to reconciling their appropriate use with their potentially serious adverse effects. NSAIDs have a profound impact on the treatment of connective tissue disorders because of their ability to address the underlying cause with specific benefits of decreasing stiffness and inflammation, and improving mobility. NSAID use is twice as common as opioid use, and inappropriate use of NSAIDs is widespread. NSAID use should be monitored and the impact understood to mitigate the risks. NSAID discontinuation should be evidence based and individualized to specific requirements.

Emerging Trends in Pain Medication Management: Back to the Future: A Focus on Ketamine

Providers face many challenges when faced with pain management. Pain is complex, difficult to understand and diagnose, and especially enigmatic to manage. The discovery of nonopioid agents for pain management has become particularly important considering the ongoing opioid epidemic. This review is focused on revisiting ketamine, an agent that has historically been used for anesthesia, in new ways to manage pain. Ketamine has unique pharmacologic properties that may prevent the development of pain as well as reduce chronic pain. This has led to the use of ketamine for perioperative analgesia as well as chronic pain syndromes. In select patients with pain refractory to other treatment modalities, ketamine may provide much needed relief.

Novel Pharmacological Nonopioid Therapies in Chronic Pain

PURPOSE OF REVIEW

Opioid use and abuse has led to a worldwide opioid epidemic. And while opioids are clinically useful when appropriately indicated, they are associated with a wide range of dangerous side effects and whether they are effective at treating or eliminating chronic pain is controversial. There has long been a need for the development of nonopioid alternative treatments for patients that live in pain, and until recently, only a few effective treatments were available. Today, there are a wide range of nonopioid treatments available including NSAIDs, acetaminophen, corticosteroids, nerve blocks, SSRIs, neurostimulators, and anticonvulsants. However, these treatments are still not entirely effective at treating pain, which has sparked a new exploration of novel nonopioid pharmacotherapies.

RECENT FINDINGS

This manuscript will outline the most recent trends in novel nonopioid pharmacotherapy development including tramadol/dexketoprofen, TrkA inhibitors, tapentadol, opioid agonists, Nektar 181, TRV 130, ßarrestin2, bisphosphonates, antibodies, sodium channel blockers, NMDA antagonists, TRP receptors, transdermal vitamin D, AAK1 kinase inhibition, calcitonin gene-related peptide (CGRP), TRPV4 antagonists, cholecystokinin, delta opioid receptor, neurokinin, and gene therapy. The pharmacotherapies discussed in this manuscript outline promising opioid alternatives which can change the future of chronic pain treatment.