SPPM Annual Meeting Reviews
The Opioid Pendulum: How to Moderate the Swing - Opioid Free Anesthesia: Pros and Cons
By Franklin B. Chiao, MD
Director of Acute Pain Management
Komansky Children’s Center
New York Presbyterian Medical Center
Assistant Professor of Clinical Anesthesiology
Weill Cornell Medical College
New York, New York
and Marisa Wiktor, DO
Children's Hospital Colorado
Assistant Professor, Anesthesiology
University of Colorado
Aurora, Colorado
In anticipated fashion, the pro/con debate of 2019 did not disappoint!
Pro: Perioperative Pain Management: Why Are We Still Using Opioids?
Thomas A. Anderson, MD, PhD
Dr. Anderson from Stanford presented opioid-sparing analgesia strategies. The focus of his discussion was on the risks associated with perioperative use of opioids, options for opioid-sparing systemic analgesic options and the development of a plan to decrease postoperative pain and opioid use.
To no surprise, Dr. Anderson listed the plethora of opioid-related adverse drug events. The unattractive adverse effects made up a long list that included nausea and pruritis, hyperalgesia, respiratory depression, chronic opioid use and mortality. The medical evidence in favor of regional anesthesia versus opioids is extremely compelling; however, not enough anesthesiologists are utilizing these techniques. Also, most of the data published is in adult surgical patients rather than the pediatric population.
There are many options to treat pain other than opioids. The options include but are not limited to behavioral and cognitive approaches, regional anesthesia and pharmacologic systemic opioid-sparing medications focusing on NMDA antagonist, NSAIDS, Alpha-2 agonists, steroids, neuromodulating medications and others.
Con: Not So Fast Partner...the Case for Prudence
Alan Bielsky, MD
Dr. Bielsky from Children’s Hospital Colorado undeniably felt that he drew the short end of the stick for this debate; however, he put together and presented an interesting debate. Even with the opioid epidemic, opioids still serve a small purpose in the practice of medicine, but BE CAUTIOUS!!!
Dr. Bielsky left us with multiple take home points. Admittedly, he mentioned that opioids have their place in management of pain, they work and can work even when given alone. Some practitioners believe they can block anything, and yes, this is true to an extent however there are sometimes limiting factors such as polytrauma, coagulopathies, nerve monitoring concerns, controversies about compartment syndrome, and drug shortages. Each person has their own pharmacogenomic profile, so effects of some analgesics may work differently and several options are good. Opioids have unintended consequences that we all are aware of, so it is best to use them in a multimodal fashion - if at all - and with a goal to not use them for a prolonged period of time.
The discussion session included a question about why Dr. Anderson showed use of fentanyl and ketamine in some of his cases. Culturally, opioid use has become so ingrained in medical institutions that PACU nurses gave him a tough time when he did not use any fentanyl, so in some instances, he uses just 1mcg fentanyl to placate their concerns. Ketamine is a good option, as adverse effects are not as lethal when compared to opioids.
