|Year : 2019 | Volume
| Issue : 4 | Page : 441-452
Opioid free onco-anesthesia: Is it time to convict opioids? A systematic review of literature
Raghu S Thota1, Seshadri Ramkiran2, Rakesh Garg3, Jyotsna Goswami4, Vaibhavi Baxi5, Mary Thomas6
1 Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre (Homi Bhabha National Institute), E Borges Road, Parel, Mumbai, Maharashtra, India
2 Department of Anaesthesiology Critical Care and Pain, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Gajuwaka Mandalam, Vishakapatnam, Andhra Pradesh, India
3 Department of Onco-Anaesthesiology and Palliative Medicine, Dr. BRAIRCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
4 Department of Anaesthesia and Critical Care, Tata Medical Centre, New Town, Rajarhat, Kolkata, West Bengal, India
5 Department of Anaesthesiology, Lilavati Hospital and Research Centre, A-791, Bandra Reclamation, Bandra, Mumbai, Maharashtra, India
6 Regional Cancer Centre, Medical College Campus, Post Bag No. 2417, Thiruvananthapuram, Kerala, India
|Date of Web Publication||13-Dec-2019|
Dr. Raghu S Thota
Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre (Homi Bhabha National Institute), E Borges Road, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
The epidemic of opioid crisis started getting recognised as a public health emergency in view of increasing opioid-related deaths occurring due to undetected respiratory depression. Prescribing opioids at discharge has become an independent risk factor for chronic opioid use, following which, prescription practices have undergone a radical change. A call to action has been voiced recently to end the opioid epidemic although with the pain practitioners still struggling to make opioids readily available. American Society of Anesthesiologist (ASA) has called for reducing patient exposure to opioids in the surgical setting. Opioid sparing strategies have emerged embracing loco-regional techniques and non-opioid based multimodal pain management whereas opioid free anesthesia is the combination of various opioid sparing strategies culminating in complete elimination of opioid usage.The movement away from opioid usage perioperatively is a massive but necessary shift in anesthesia which has rationalised perioperative opioid usage. Ideal way moving forward would be to adapt selective low opioid effective dosing which is both procedure and patient specific while reserving it as rescue analgesia, postoperatively. Many unknowns persist in the domain of immunologic effects of opioids, as complex interplay of factors gets associated during real time surgery towards outcome. At present it would be too premature to conclude upon opioid-induced immunosuppression from the existing evidence. Till evidence is established, there are no recommendations to change current clinical practice. At the same time, consideration for multimodal opioid sparing strategies should be initiated in each patient undergoing surgery.
Keywords: Cancer recurrence, interdisciplinary pain management, onco-anesthesia, opioid free anesthesia, opioid free onco-anesthesia, opioid sparing anesthesia
|How to cite this article:|
Thota RS, Ramkiran S, Garg R, Goswami J, Baxi V, Thomas M. Opioid free onco-anesthesia: Is it time to convict opioids? A systematic review of literature. J Anaesthesiol Clin Pharmacol 2019;35:441-52
|How to cite this URL:|
Thota RS, Ramkiran S, Garg R, Goswami J, Baxi V, Thomas M. Opioid free onco-anesthesia: Is it time to convict opioids? A systematic review of literature. J Anaesthesiol Clin Pharmacol [serial online] 2019 [cited 2020 Jan 27];35:441-52. Available from: http://www.joacp.org/text.asp?2019/35/4/441/272924
| Introduction|| |
Sir Thomas Sydenham quoted 'Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium'.
With the emergence of need of effective pain control, pain was considered an important vital sign for clinical documentation and declared as fifth vital sign. Pain control started getting equated with quality control in the health system due to administrator governance. The opioid remained the acceptable modality for pain management. The tide of opioid use gradually paved way for prescription misuse and an expected overuse so much so, that in 2017 the United States had to declare an opioid crisis., The need to incorporate opioid sparing strategies has been emphasised with usage of regional anesthesia techniques as part of multimodal pain management in perioperative setting. The onus is now on us, to gear up with the change and embrace best practises towards opioid sparing anaesthesia to address the public health care crisis.
At one extreme in the developed world, United States Centre for Disease Control (CDC) issued warning that prescription opioids are the major drug problem., Unfortunately, at the other extreme in the developing world, pain practitioners are still struggling to make opioids readily available to patients undergoing cancer surgeries, highlighting the actual drug problem. This gap is further going to widen if restrictions and impositions are sanctioned against prescribing opioids. To understand the concerns, we conducted this review related to opioid usages and opioid sparing techniques for pain management.
| Methodology|| |
The research question for initiating the review was 'opioid sparing strategies/opioid free anesthesia in Onco-Anesthesia practice' in which participants, intervention, comparison, outcome and study design (PICOS) format was followed for this review as per the 'PRISMA' statement.
The components included were:
Patients undergoing oncological treatment/surgical procedure.
Use of opioid sparing strategies for perioperative analgesia.
Opioid free anesthesiapractice.
Cancer recurrence, progression, metastatic spread, outcome and overall survival with respect to usage/abstinence from opioids.
The review included both prospective and retrospective randomised clinical as well as cohort studies. Relevant editorial review, letter to editor, meta-analysis and review articles were also considered. Isolated case reports, animal studies,in vitro experimental studies, studies on human volunteers and case series studies were however excluded.
The explorative search was done from PubMed, PubMed central, Cochrane Library, Google Scholar and Embase databases for all the related manuscripts from January 2000 till March 2019. The keywords used included opioid use, misuse and abuse, 'opioid sparing strategies,' 'opioid free anesthesia,' 'opioid free Onco-anesthesia,' 'opioid sparing Oncoanesthesia,' 'moving away from opioid based Onco-anesthesia,' opioid adverse effects including hyperalgesia and tolerance, 'opioid crisis,' 'surgery without opioids,' 'opioid and enhanced recovery after surgery,' 'regional anesthesia based opioid sparing,' 'loco-regional anesthesia in cancer surgery,' 'opioid sparing in cancer surgery outcome,' 'recurrence, metastasis and survival based cancer surgery outcome with opioid based and opioid sparing/opioid free anesthesia,' 'opioids and immune suppression and cancer recurrence,' non-opioid and non-pharmacologic strategies in acute/chronic pain and opioid alternatives. Further relevant manuscripts were manually searched from the bibliography of the searched manuscripts.
| Results|| |
Of the 3000 searched manuscripts, the present review included 116 manuscripts [Figure 1] inclusive of all types of published manuscripts that fulfilled the 'PICOS' criteria as defined for our research question. Of these, only 48 manuscripts were reviewed for high quality and non-repetitive content.
The titles, abstract and content were manually screened carefully to assess the suitability for inclusion in the review. The process of screening included factors such as language, available publication data, abstracts with full text availability, its relevance and study type with emphasis on meta-analysis, systematic review, highly relevant review articles, randomised control studies, editorials and retrospective studies in hierarchical order. The characteristics of the studies included are summarised in [Table 1].,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
| Discussion|| |
This systematic review of the literature provided the insight about the appropriate and optimal use of opioids in perioperative setting of the patient undergoing cancer surgeries. Opioid sparing strategies have emerged embracing loco-regional techniques and non-opioid based multimodal pain management, whereas opioid free anesthesia is the combination of various opioid sparing strategies culminating in complete elimination of opioid usage. The recent concerns about the opioid-related misuse and its effects on cancer outcome have been instigated. It justifies the need not to eliminate opioid from practice, but to adapt an effective as well as selectively low opioid dosing which is both procedure and patient specific while reserving it as rescue analgesia postoperatively.
Opioid crisis fact file: The recent concerns related to opioid use/misuse may be attributed to certain facts that need to be understood. Some of these are:
- Opioid use begets opioid use: The primary treatment of post-surgical pain is opioid. More opioids are prescribed postoperatively for pain control in the pretext of quality of care
- 'Opioid-paradox': The more the opioids used intraoperatively, the more shall be the requirement postoperatively. This paradoxical phenomenon is due to sensitisation of opioid receptor and the tolerance developed which further leads to hyperalgesia
- Preventing opioid naïve patients from becoming chronic users: Opioid naïve patients, previously unexposed to opioids undergoing short duration surgery developed opioid dependence by one year after surgery due to faulty iatrogenic prescription practises. Risk factors attributed were young adults with lower income associated with higher intra-operative opioid usage extending beyond the duration of acute post-operative period
- Repeated morphine doses administered postoperatively prolongs pain further, which may end up in persistent post-surgical pain (PPSP) in animal models. Beginning with third post-operative day, each dose of opioid prescription translates to chronic opioid use disorder. About 50% of opioid naïve patients are given an opioid prescription postoperatively, out of whom 3.1% continue to use beyond 3 months contributing to chronic opioid user pool. This has led to an iatrogenic addiction,
- 75% heroin users admitted having initially started off with a left-over prescription opioid which later led to addiction,
- Amidst an increasing trend of opioid-related death, closed claims revealed that 88% of opioid-related death (ORD) occurred within 24 postoperative hours due to undetected respiratory depression especially in the obese. The epidemic of opioid use, misuse and abuse has resulted in significant morbidity as well as mortality., Incidence of opioid-related deaths due to respiratory depression causing hypoxia, brain damage leading to death was 0.1-37%.,
Why to switch over from balanced anesthesia to opioid sparing?
Though John Lundy introduced the term 'balanced anesthesia' in 1926, it was Kehlet in 1989 who revolutionised the concept of balanced anesthesia by amalgamating opioids and non-opioids in clinical practise., Prior to the conception of opioids in anesthetic practise in 1960s, high dose thiopental sodium and inhaled anesthetics were being used to achieve hypnosis, amnesia and immobility. Suppression of autonomic response became viable after the introduction of opioids. The inclusion of non-opioids along with opioids synergised the concept of balanced anesthesia by improving postoperative pain control and negating the opioid adverse effects.,,,,,
The dawn of opioid free anesthesia (OFA)
Opioid free anesthesia (OFA) is defined as the combination of various opioid sparing strategies culminating in complete avoidance of perioperative opioid usage to reduce opioid-induced adverse effects without sacrificing patient comfort.,, OFA ideally includes loco-regional techniques, nonopioid analgesics and antihyperalgesics for an integrated pain management.,
Jan Paul Mulier in 2012 proposed OFA in obese patients undergoing bariatric surgery and showed improved outcomes with shorter hospital stay especially in patients with obstructive sleep apnoea.,, Initially a combination of intravenous dexmedetomidine, ketamine and lignocaine were utilised to which newer additions like magnesium sulphate, gabapentin, dexamethasone, paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDS), cyclo-oxygenase-2 (COX-2) inhibitors were made subsequently., The addition of local anesthetic infiltration (liposomal bupivacaine) and locoregional blocks (fascial plane regional blocks, central neuraxial blocks) further enhanced pain management.
The goal of opioid free anesthesia is to rationalise perioperative opioid use by avoiding intraoperative opioids, spare opioids to limited postoperative use at the same time reducing its usage, preventing persistent post-surgical pain, enhancing early recovery without compromising patient comfort.,,,,,,, OFA avoids opioid-related adverse effects, tolerance and hyperalgesia that had been taken for granted after general anesthesia., Specific indications for OFA include chronic preoperative pain treated with opioids, opioid substance use disorder, obesity linked obstructive sleep apnoea, complex regional pain syndrome (CRPS) and persistent post-surgical pain (PPSP).
Opioid free anesthesia: A paradigm shift
The movement away from opioid usage perioperatively is a massive but necessary shift in the thinking which has gone beyond the boundaries of bariatric surgery and penetrated onco-anesthesia practise. This shift has embraced locoregional techniques along with nonopioid based multimodal pain management [Figure 2] to gear-up the rejuvenation in regional anesthesia practise and rationalising perioperative opioid usage. It's the shift breaking the link with acute opioid exposure against developing an opioid dependence on chronic exposure which is now being considered with a different regard.,,,,,
|Figure 2: Adopted from 'New paradigm in analgesia management'. (With kind permission from Dr. Michael Manning 'The rising tide of opioid use and abuse: Role of Anesthesiologist'. Perioper Med 2018 Jul 3;7:16)|
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OFA – What about patient comfort?
Hontoir addressed the concerns of patient comfort with opioid free anesthesia and satisfaction scores postoperatively in patients undergoing breast surgery. The QOR-40 (quality of recovery by 40 questionnaires) scores were utilised for satisfaction scoring. Both the opioid free and opioid based groups had comparable analgesic requirement postoperatively and at 24 hours. The only drawback of the study being the utility of piritramide (Meperidine-related weak mu agonist) as the choice of postoperative analgesia hence rendering it not strictly opioid free.
Are perioperative opioids obsolete? Opioids- being a friend to becoming foe
By including multimodal nonopioid based analgesia, perioperative opioids will no longer be routinely needed as default analgesia if dealt with an integrated multimodal approach., At the same time, no patient should be deprived of opioids if need arises.
Opioid sparing strategies: Looking at opioid alternatives
Multimodal interdisciplinary pain management approach [Figure 3] to opioid sparing has the advantage of using lowest effective opioid dose, lessening the risk of opioid misuse/abuse, combating opioid-induced hyperalgesia postoperatively and allowing safer use of each drug in lower dose with each having a different mechanism of action., There are many benefits of opioid sparing anesthesia strategies[Table 2]. Paracetamol, NSAIDS and COX-2 inhibitors bring about 24–31.6% opioid sparing effect and significant reduction (30%) in opioid-related adverse events., Addition of nonopioid adjuncts like α-2 agonist, low dose ketamine, gabapentinoids, magnesium sulphate, dexamethasone adds 20–50% further to opioid sparing.,,,, Non-pharmacological techniques like ultrasound, cold laser, high intensity laser therapy (HILT), cryotherapy, acupuncture, physiotherapy, psychotherapy incorporating cognitive behavioural therapy, electrotherapy involving transcutaneous electrical nerve stimulation (TENS) further alleviate pain postoperatively when used as an integrated interdisciplinary pain management.,,
|Table 2: Benefits of adapting opioid sparing strategies in anesthesia practice|
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Opioid sparing or opioid free anesthesia: Which is the way forward?
The greatest enigma to pain research has been opioid-induced hyperalgesia and persistent post-surgical pain. Liberal opioid prescription has stemmed the emergence of hyperalgesia (especially continuous remifentanil infusion with its abrupt withdrawal). High doses of neuraxial fentanyl have also been linked to higher pain scores and to increase postoperative opioid requirements. Neither of them represents hyperalgesia in the true sense though, as actual central sensitisation is not evident.
Ideal way moving forward would be to adapt selective low opioid effective dosing, optimising perioperative opioid usage (both procedure and patient specific) and to reserve opioid as rescue analgesia postoperatively.,, Synergistic nonopioid adjuncts, locoregional techniques and non-pharmacologic integral pain therapy will facilitate comfort and enhance recovery. A critical evaluation of opioid dosing is paramount in each patient. Refraining from use of high dose of perioperative opioids and routine postoperative opioid prescription shall be the responsibility of each pain practitioner in preventing the opioid crisis.
Opioid-induced immunosuppression. Is there evidence?
Many unknowns persist in the domain of immunologic effects of opioids, as complex interplay of factors [Figure 4] influence host immune response.,,, To establish causation linked immunosuppression to opioids would be impossible in human studies considering ethical hurdles. In order to reproduce tumour biology and its behaviour with immune system, the clinical outcome studies should be performed on cancer patients undergoing real time surgery assessing the outcome progression prospectively and not by retrospective studies designed for hypothesis generation., Rather, pain itself is immunomodulatory and detrimental along with surgical stress response.,,
At present it would be too premature to conclude upon opioid-induced immunosuppression from the existing evidence.
Evidence-based recommendations for opioid use in Onco-anesthesia
- Are opioids immune modulatory: Immunomodulation effects of opioids in the form of NK cell suppression found in animal studies are not demonstrable in human opioid studies,,
- Are opioids safe to treat perioperative and chronic pain: Clinical studies have failed to demonstrate adverse outcomes in patients receiving opioids for cancer pain., Recent data from refined animal models suggest that opioids are safe
- Are opioids safe in pediatric pain: No adverse developmental, behavioural and cognitive integral effects of opioids in pediatric population
- Are opioids implicated in cancer recurrence: Opioid-tumour interaction is complex and not well defined. Opioid effects on cancer recurrence are contradictory and not well established,,,
- Do opioids affect cancer outcomes: Opioid effects on overall cancer survival and outcome are not causal. There is no substantial evidence against opioids in the causation of tumour recurrence, spread and metastasis.,
Opioid versus regional anesthesia: Evidence?
Studies have linked regional anesthesia with favourable cancer outcomes retrospectively. The meta-analysis by Cakmakkaya et al. had suggested no advantage on survival outcome with neuraxial blockade compared with systemic opioids in cancer surgery. Cochrane review did conclude against any beneficial survival outcomes with regional anesthesia due to lack of quality of evidence.,
Regional anesthesia has not been shown to be universally beneficial over opioids (other than superior pain relief and anti-inflammatory effect) with respect to preventing recurrence and influencing outcome in cancer surgery.,,,,,, Singling out one intervention in a multifaceted, complex, dynamic perioperative setting to establish cancer outcomes would be disastrous., Perioperative opioid sparing leading to better long-term outcome needs to be proven beyond doubt with high quality cancer pain studies until which opioids should continue to be recommended in cancer pain management.,
Anesthetic technique and cancer recurrence. Evidence or speculation?
Will anesthetic technique or the choice of analgesic influence cancer outcomes and metastasis? Heaney and Buggy have dissected the association intricately. Metastatic recurrence remains frustratingly common entity which is invariably difficult to treat., Unfortunately, perioperative period is the most critical window for cancer recurrence considering the multitude factors having an interplay with inflammatory mediators including cytokines, neuromodulators, endocrine system activators, metabolic and immunologic signalling pathways.,, Surgical stress, pain, tumour handling activates numerous biological cascades leading to immunosuppression culminating in perturbations in cellular signalling initiating a cascade of immunoediting and immunomodulation.,,,
Seeding by micro-embolisation allows the spread of cancer which along with the circulating tumour cells (CTC) become responsible for metastasis and recurrence.,, Unfortunately, the surgical procedure intended for cure now creates a period of susceptibility overcoming host defence, leading to dissemination of residual cancer cells into circulation by microembolisation due to tumour handling or by a pre-existent micro-metastasis seeding resulting in an established metastasis.,,
In vitro animal studies and data from retrospective studies with hypothesis generation should not be extrapolated to evidence. The choice of opioids, non-opioid adjuncts, regional anesthesia techniques, volatile anesthetics and propofol-based TIVA derived fromin vitro experimental studies yielding conflicting results (from deleterious to null to protective effects) cannot be considered as evidence towards cancer causation, recurrence, spread and outcome. Prospective human studies despite ethical hurdles are needed to establish an evidence towards causation of cancer recurrence with the choice of anesthetic technique, which may provide an insight into future.,
Till evidence is established, there are no recommendations to change current clinical practise.,, It will be too premature to make any recommendation regarding the ideal anaesthetic technique till results from evidence based prospective human studies become available.,,, There is no evidence to state that a change in either anesthetic technique or practise could have an impact on survival outcomes in cancer patients.,,, Opioids shall continue to be a part of multimodal pain management both in the perioperative and in chronic cancer pain management.
Opioid free anesthesia (OFA) in an era of ERAS
Enhanced recovery after surgery (ERAS) is a multi-dimensional approach to reduce length of hospital stay involving a rational set of perioperative goals targeting early ambulation, gut motility, enhanced nutrition, thromboprophylaxis by integrating goal directed fluid management, ventilatory strategies and optimising perioperative hemodynamics. The incorporation of aggressive postoperative pain management also targets an early recovery.,,
High dose opioid increases length of hospital stay, delays early recovery and return to normalcy., OFA has favourable profile leading to early recovery (although sedation may hinder early discharge from PACU) and reduction in postoperative hyperalgesia. Enhanced recovery pathway incorporating OFA provides a platform for addressing patients with opioid addiction and ensuring their safe transition into postoperative recovery.
Goal of ERAS is to provide 'optimal analgesia' which optimises patient comfort, facilitates early functional recovery while minimising adverse effects of opioids. Cancer specific ERAS pathway in Onco-anesthesia will be the next big thing happening in cancer research which will be specific to the subtype of cancer surgery.,,
| Summary|| |
It is more important to address issues like surgical stress, persistent post-surgical pain, prevention of hyperalgesia, transfusion-related immunomodulation, hypothermia-related deleterious effects, importance of prewarming, malnutrition correction, improving functional capacity by pre-habilitation and integrating interdisciplinary pain management among cancer patients undergoing surgery rather than to delve upon opioid-induced immune-homeostasis disruption. Opioid sparing strategies involving an emergence of loco-regional techniques is a welcome trend, but not at the expense of opioid conviction. Opioids would still be recommended as the primary rescue analgesia in acute postoperative as well as in the chronic cancer pain management despite the current global opioid epidemic crisis and no patient in need should be deprived of opioids. There is no current evidence to support any change in clinical anesthesia practise. At the same time, consideration for multimodal opioid sparing strategies should be initiated in each patient undergoing surgery. Well, let's begin opioid sparing…
We acknowledge, Michael W. Manning, Assistant Professor, Division of Cardiothoracic Anesthesia, Division of General, Vascular and Transplant Anesthesia, Duke Cardiovascular Research Centre, Duke University, Durham, NC-27710. For permitting the usage of the Figure “New paradigm in analgesia management”, from his article, The rising tide of opioid use and abuse: the role of the anesthesiologist. Perioper Med (Lond).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]