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• W2940329804 abstract "Perioperative opioid receptor agonism has a range of patient benefits. In this issue of the British Journal of Anaesthesia, Egan1Egan T. Are opioids indispensable for general anaesthesia?.Br J Anaesth. 2019; 122: e127-e135Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar provides an eloquent reminder that during the intraoperative period, when the body is subject to the controlled trauma of surgery, opioids can powerfully modulate the autonomic nervous system (ANS) response to nociception. In doing so, they offer a substantial minimum alveolar concentration (MAC) reduction effect, allowing unconsciousness and immobility to be obtained with lower doses of hypnotic or volatile agent than would otherwise be required during general anaesthesia. In addition, restraining sympathetic nervous system activation during surgery is a physiologically attractive proposition, given the deleterious effects on myocardial oxygen demand caused by tachycardia, heightened contractility and raised afterload. Increased heart rate (as a readily measurable, ANS-influenced variable) is known to be associated with cardiovascular morbidity and mortality in the general population,2Bohm M. Reil J.C. Deedwania P. Kim J.B. Borer J.S. Resting heart rate: risk indicator and emerging risk factor in cardiovascular disease.Am J Med. 2015; 128: 219-228Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar patients undergoing non-cardiac surgery,3Landesberg G. Beattie W.S. Mosseri M. Jaffe A.S. Alpert J.S. Perioperative myocardial infarction.Circulation. 2009; 119: 2936-2944Crossref PubMed Scopus (344) Google Scholar and the critically ill.4Sander O. Welters I.D. Foëx P. Sear J.W. Impact of prolonged elevated heart rate on incidence of major cardiac events in critically ill patients with a high risk of cardiac complications.Crit Care Med. 2005; 33: 81-88Crossref PubMed Scopus (90) Google Scholar For these reasons, there is widespread acceptance that sustained periods of tachycardia should be avoided during surgery, even if the means by which we do so remain contentious.5Foëx P. Higham H. Preoperative fast heart rate: a harbinger of perioperative adverse cardiac events.Br J Anaesth. 2016; 117: 271-274Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar In addition to ANS-response modulation, perioperative opioid-receptor agonism provides a highly efficacious treatment of acute, severe, post-surgical pain. The pharmacodynamic effects of opioids can be profoundly beneficial when the specific clinical scenario requires some combination of analgesia, anxiolysis, sedation, and/or euphoria.6Pathan H. Williams J. Basic opioid pharmacology: an update.Br J Pain. 2012; 6: 11-16Crossref PubMed Google Scholar The provision of analgesia (by whatever method) is both an end in itself and an important means of facilitating functional recovery after surgery,7Kehlet H. Dahl J.B. Anaesthesia, surgery, and challenges in postoperative recovery.Lancet. 2003; 362: 1921-1928Abstract Full Text Full Text PDF PubMed Scopus (1049) Google Scholar although it has long been recognised that opioid monotherapy is not the best way to achieve this.8Kehlet H. Rung G.W. Callesen T. Postoperative opioid analgesia: time for a reconsideration?.J Clin Anaesth. 1996; 8: 441-445Crossref PubMed Scopus (141) Google Scholar Opioids, however, possess the pharmacokinetic strength of being a well-studied family of drugs, enjoying multiple routes of administration, a plethora of delivery methods, and a wide range of durations of action. Add to these pharmacological advantages the economic reality (most relevant in resource-poor health economies) that they are inexpensive and simple to manufacture, and it is apparent why opioids have been the keystone of the management of acute, severe, postoperative pain for more than 160 yr.9Brownstein M.J. A brief history of opiates, opioid peptides, and opioid receptors.Proc Natl Acad Sci USA. 1993; 90: 5391-5393Crossref PubMed Scopus (324) Google Scholar Nevertheless, the practical disadvantages of opioid administration are manifold and include confusion, hallucinations, urinary retention, pruritus, respiratory depression, and gastrointestinal disturbance.10Banyamin R. Trescot A.M. Datta S. et al.Opioid complications and side effects.Pain Physician. 2008; 11: S105-S120Google Scholar These complications are sufficiently common for ‘opioid sparing’ to be popular as a clinically impactful outcome measure in clinical trials assessing the efficacy of alternative analgesic strategies. To the existing catalogue of opioid-related adverse events, we can now add population-level opioid use disorder, as initial scepticism that short-term perioperative prescribing is associated with subsequent addiction11Porter J. Jick H. Addiction rare in patients treated with narcotics.NEJM. 1980; 302: 123Crossref PubMed Scopus (4) Google Scholar, 12Max M.B. Improving outcomes of analgesic treatment: is education enough?.Ann Intern Med. 1990; 113: 885-889Crossref PubMed Scopus (200) Google Scholar seems far from correct.13Schuchat A. Houry D. Guy G.P. New data on opioid use and prescribing in the United States.JAMA. 2017; 318: 425-426Crossref PubMed Scopus (211) Google Scholar Such is the concern among anaesthetists about opioid-related adverse drug events that there is increasing interest in ‘opioid-free’ anaesthesia,14Frauenknecht J. Kirkham K.R. Jacot-Guillarmod A. Albrecht E. Analgesic impact of intraoperative opioids versus opioid-free anaesthesia: a systematic review and meta-analysis.Anaesthesia. 2019; 25 (Advance access published on February 25)https://doi.org/10.1111/anae.14582Crossref Scopus (128) Google Scholar although there is no agreement about what does or does not constitute such a technique.15Elkassabany N.M. Mariano E.R. Opioid-free anaesthesia – what would Inigo Montoya say?.Anaesthesia. 2019; 25 (Advance access published on February 25)https://doi.org/10.1111/anae.14611Crossref Scopus (15) Google Scholar In the context of this multitude of disadvantages, how do we assimilate Egan's cogent framework addressing intraoperative use of opioids during general anaesthesia? First, we acknowledge the role that remifentanil now plays in allowing us to control intraoperative nociceptive responses with minimal impact on the postoperative period.16Feldman P.R. James M.K. Bracken M.F. et al.Design, synthesis, and pharmacological evaluation of ultrashort- to long-acting opioid analgesics.J Med Chem. 1991; 34: 2202-2208Crossref PubMed Scopus (193) Google Scholar The popularity of this ultrashort-acting opioid as a counter-balance to either intravenous or inhalational-based general anaesthesia deservedly continues, despite evidence suggesting that (like its longer-acting cousins) it can induce postoperative opioid tolerance and hyperalgesia (especially when used in high doses during anaesthesia).17Yu E.H.Y. Tran D.H.D. Lam S.W. Irwin M.G. Remifentanil tolerance and hyperalgesia: short-term gain, long-term pain?.Anaesthesia. 2016; 71: 1347-1362Crossref PubMed Scopus (123) Google Scholar In this regard, we caution the use of remifentanil as ‘the forgiving drug’ (because of its favourable pharmacokinetics and pharmacodynamics), and recommend that it is used in a dose adequate to achieve ANS damping, while avoiding high doses in an attempt to produce ‘hypnotic-sparing’. Second, we hope that the continued expansion of minimally invasive operative techniques (including laparoscopy, thoracoscopic, endoscopy, endovascular, and percutaneous procedures) will see fewer and fewer patients exposed to the autonomic, nociceptive, and immunological insults of open surgery, and, therefore, that our need for intraoperative opioid use will continue to dwindle. Third, the transformative effect of regional anaesthesia on two of the three pillars of ‘balanced’ general anaesthesia—namely immobility and control of autonomic responses—should lead us to consider peripheral or central nerve blockade for any applicable procedure. Indeed, such are the intraoperative and immediate postoperative benefits of well-delivered regional anaesthesia that it has entirely superseded general anaesthesia as the technique of choice for many procedures for many anaesthetists, even in the absence of compelling evidence of longer-term impact on surgical outcome.18Hopkins P.M. Does regional anaesthesia improve outcome?.Br J Anaesth. 2015; s2: 26-33Google Scholar Given that anaesthetists have a role to play in combatting opioid use disorder,19Alam A. Juurlink D.N. The prescription opioid epidemic: an overview for anesthesiologists.Can J Anesth. 2016; 63: 61-68Crossref PubMed Scopus (57) Google Scholar it seems prudent to conclude with a summary of practical steps recommended when considering integrating opioids into a technique of general anaesthesia and postoperative pain management. Some of these are described in detail by Soffin and colleagues.20Soffin E.M. Lee B.H. Kumar K.K. Wu C.L. The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse.Br J Anaesth. 2019; 122: e198-e208Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar•Use existing preoperative consultations to prepare patients for expected acute post-surgical pain and its management and enter patients into planned pathways of enhanced recovery.•Identify patients at greatest risk of opioid use disorder (pre-admission opioid use, chronic pain, depression, anxiety, alcohol or substance misuse).•When managing ANS responsiveness during anaesthesia, optimise the balance between hypnotics and analgesics to avoid overshoot in opioid administration; avoid large doses of opioids to provide ‘hypnotic-sparing anaesthesia’.•Maximise non-opioid, multimodal analgesic techniques, including intravenous (e.g. ketamine, lidocaine), and local and regional techniques for intraoperative autonomic response control and postoperative pain relief. Alongside, review the basis on which modified-release opioids are prescribed in specific clinical contexts.21Levy N. Mills P. Controlled-release opioids cause harm and should be avoided in management of postoperative pain in opioid naïve patients.Br J Anaesth. 2019; 122: e86-e90Abstract Full Text Full Text PDF Scopus (22) Google Scholar•Optimise multimodal, postoperative pain management before stopping intraoperative analgesics using principles of pharmacokinetics and pharmacodynamics (e.g. onset time, clearance), thus avoiding ‘valleys of absent analgesia’, leading potentially to sensitisation and hyperalgesia.•Engage in local reviews of postoperative opioid prescribing, including weaning and de-prescribing planning, discharge medicines audit and evaluation of post-discharge opioid consumption and wastage. In summary, we welcome Egan's1Egan T. Are opioids indispensable for general anaesthesia?.Br J Anaesth. 2019; 122: e127-e135Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar review, which analyses the place of opioids in modern anaesthetic practice, and considers whether they are indispensable. We provide a practical framework that we hope will assist anaesthetists in rationalising intraoperative opioid use. We recommend that anaesthetists consider the impact of intraoperative opioid administration, and recommend that they remain mindful of the impact of intraoperative opioid administration on sensitisation, hyperalgesia, and opioid use disorder. MMRFS is a director and JGH is associate editor-in-chief of the British Journal of Anaesthesia. The good, the bad, and the ugly: the many faces of opioidsBritish Journal of AnaesthesiaVol. 122Issue 6PreviewOpium, an extract of the poppy Papaver somniferum, has been used for centuries for the alleviation of pain and suffering. This beneficial effect, as with most medications, is offset by a number of serious side-effects including respiratory depression, constipation, tolerance, and dependence.1 Tolerance and dependence unmask a darker side to opioids that has fuelled two historic opium wars in China, the current worldwide opioid ‘epidemic’, and a general vilification of the opioid drug class. This issue of British Journal of Anaesthesia includes a special section after a call for papers on this subject. Full-Text PDF Open Archive" @default.
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• W2940329804 title "Opioids: refining the perioperative role of God's own medicine" @default.
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