Opioid-free anaesthesia - Ways out of the opioid crisis and the future of perioperative patient management?

Opioids are long known for playing a central role in multimodal analgesia perioperatively. Thus, it appears odd to provide anaesthesia and analgesia without the perioperative use of opioids to improve morbidity and mortality. However, this is recommended by the new concepts of opioid free anesthesia and opioid free anaesthesia and analgesia. While patients will be protected from unwanted side effects of opioids, such as respiratory depression or impaired gastrointestinal function, the coverage of surgery induced nociception relies on non-opioid adjuvants, for example dexmedetomidine or ketamine, and regional anaesthesia. Enhanced Recovery after Surgery (ERAS) protocols, the ongoing debate on opioids and tumor biology as well as the opioid pandemic in Northern America, helped to spread the idea of these concepts. Especially patients who suffer from sleep apnea, chronic pain conditions or are on chronic opioid therapy, seem to benefit from avoiding opioids intraoperatively. In contrast to opioid free anaesthesia and analgesia, opioid free anaesthesia is indeed feasible, yet not without challenges. Potential adverse drug interactions of non-opioid medications or sufficient monitoring of intraoperative nociception are only two examples that require further discussion. Future evidence has to show, if opioid free anaesthesia will improve perioperative outcome in certain patient populations before leaving the long-established concept of opioid based multimodal anaesthesia behind.