Author response on Opioid Free Anesthesia and the Law of Unintended Consequences
Lynn D. Martin, MD MBA and Daniel K.W. Low, MBBS
I received several responses on the recent PAADs on Opioid Free Anesthesia and the Law of Unintended consequences. This one from Drs. Martin and Low is important and long enough to merit its own PAAD posting. Over the next few weeks we have several more articles primarily from the September issue of Anesthesia and Analgesia that addresses many of these issues. So stay tuned. Myron Yaster MD
From Lynn D. Martin, MD MBA, Professor Emeritus, Anesthesiology and Pain Medicine, University of Washington School of Medicine and Daniel K.W. Low, MBBS, Associate Professor, Anesthesiology and Pain Medicine University of Washington School of Medicine
We read with interest both of your reviews of our most recent manuscript last week and the subsequent counterpoint article by Santa Cruz Mercado LA, et al. (1) We applaud these investigators efforts to better understand the outcomes of our anesthesia practices. We would like to make several important points for you and your readers’ consideration.
(1) We have not advocated nor suggested that opioid-free anesthesia (OFA) is a solution for the opioid epidemic. Some of us may have wondered if these efforts could mitigate the problem knowing that 1 in 12 opioid-naive patients end up refilling opioid prescriptions >90 days after surgery. The opioid epidemic was never the primary driver for our decision to try OFA. In the original trial, I (LDM) directed my team to reduce anesthesia medication costs for our most common procedure (adenotonsillectomy) knowing full well that the team would remove costly IV acetaminophen. They replaced it with dexmedetomidine. The initial effort used 50% of our previous opioid dose with dexmedetomidine. With daily monitoring of outcomes, the trial was halted after 3 days due to excessive somnolence in the PACU. The team then proposed dexmedetomidine only (no opioid). Because I had been trained by both Drs. Yaster and Maxwell to always use an opioid for painful surgery, I was extremely skeptical that OFA would succeed, but willing to try it knowing I could monitor outcomes daily. I was proven wrong. We saw reductions in PACU opioid rescue and PONV rates without changes in mean maximum PACU pain scores or length of stay. (2)
(2) There is compelling evidence that limiting opioid use for surgical care as part of a multimodal analgesia enhanced recovery after surgery (ERAS) protocol improves outcomes for both adults and children. (3,4) Aware of the growing ERAS data, the team used our initial OFA success to replicate this practice for all ambulatory surgeries (5) and then for select higher acuity inpatient cases (6). We want to emphasize that our protocols do not simply stop opioids, we are replacing them with non-opioid multi-modal alternatives and using regional anesthesia whenever possible.
(3) We see the study by Santa Cruz Mercado and ours as an ‘apples to oranges’ comparison. The patient populations are very different (adult vs children). They were studying the pharmacodynamic dose-response relationship of opioids on post-operative pain. Unsurprisingly they showed that lower intraoperative doses of opioids (without non-opioid alternatives) were associated with higher pain scores and subsequent use of opioids. In our studies, we are replacing opioids with multimodal non-opioid alternatives (dexmedetomidine, ketorolac, ketamine, acetaminophen) and regional anesthesia. We now have data from 53,734 OFA patients from our ASC and hospital. While average maximum pain scores in the PACU are unchanged (mean 3.5), other key measures show clear benefits for OFA (see table below).
Based on these newly acquired OFA data (lower pain scores and opioid use) along with evidence in the literature recommending tailoring the postoperative opioids prescribed based on postoperative pain and opioid use (7), our surgeons over the last 2.5 years have modified their pain prescription practices. They have reduced opioid prescription dose counts by 50% while maintaining only 1.1% opioid prescription refills (see below; note the last 4 points on refill chart are nil values as 90 days has not passed).
In closing, Myron and Lynne were right, an opioid was an essential (required?) element for a successful balanced anesthetic in the 1980-90s. However, they also taught me another important lesson: question dogma. Anesthesiologists must continue to grow and evolve our practice of anesthesiology, sometimes by reevaluating old dogma, if we are going to survive as a viable medical specialty. Using real-world experience and data, we are tilting at the windmills!!!
References
1. Santa Cruz Mercado LA, Liu R, Bharadwaj KM, et al. Association of intraoperative opioid administration with postoperative pain and opioid use. JAMA Surg. 2023;158:854-64. doi:10.1001/jamasurg.2023.2009.
2. Franz AM, Dahl JP, Huang H et al. The development of an opioid sparing anesthesia protocol for pediatric ambulatory tonsillectomy and adenotonsillectomy – a quality improvement project. Pediatr Anesth. 2019;29:682-89. doi 10.1111/pan.13662.
3. Franz AM, Martin LD, Liston DE, et al. In pursuit of an opioid-free pediatric ambulatory surgery center: a quality improvement initiative. Anesth Analg. 2021;132:788-97. doi:10.1213/ANE.0000000000004774.
4. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surgery. 2017;152:292-98. doi:10.1001/jamasurg.2016.4952.
5. Brindle ME, Heiss K, Scott MJ, et al. Embracing change: the era for pediatric ERAS is here. Pediatr Surg Int. 2019;35:631-4. doi:10.1007/s00383-019-04476-3.
6. Martin LD, Chiem J, Hansen E, et at. Completion of an enhanced recovery program in a pediatric ambulatory surgery center: a quality improvement initiative. Anesth Analg. 2022;135:1271-81. doi 10.1213/ANE.0000000000006256.
7. Kelly-Quon LI, Kirkpatrick MG, Ricca RL, et al. Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion. JAMA Surgery. 2021;156:76-90. doi:10.1001/jamasurg.2020.5045.