Is Universal Opioid-Free Anesthesia a Realistic Target? IARS Experts Debate This Timely Question

Jordan Francke, MD, MPH

IARS experts led a lively debate on how anesthesiologists should be targeting the use (or restraint) of opioids in the perioperative space in the session, “Less Opioid, More Recovery? Debating the Future of Surgical Pain Management,” held on Saturday, May 2, at the 2026 Annual Meeting, presented by IARS and SOCCA. Opioids provide potent analgesia to treat severe intraoperative and postoperative pain, but are also associated with a host of adverse effects and some of them can be lethal. The debate was co-moderated by Thomas Anderson, MD, clinical professor in the Department of Anesthesiology, Perioperative and Pain Medicine, at Stanford University, and Christopher Haley, MBChB, MScHQ, FRCPC, FRCA, assistant professor at Kingston Health Sciences Centre.

The first speaker James Rathmell, MD, MBA, Leroy D. Vandam Distinguished professor of anaesthesia at Harvard Medical School and Editor-in-Chief of Anesthesiology. In his role at the journal, Dr. Rathmell has seen an increasing number of submissions related to both opioid-free (i.e., complete absence of opioids during the perioperative period) and opioid-sparing (i.e., conscious minimization of the total amount of opioids administered) anesthetic and analgesic regimens. As far back as the 1960s, it was demonstrated that large dosages of intravenous opioids were effective in providing excellent perioperative analgesia with minimal hemodynamic consequences in the frailest of patients. However, in recent years 5-10% of patients will have persistent use of opioids after surgery, which can be associated with respiratory depression, ileum, delirium, and even paradoxically opioid-related hyperalgesia. While they do work, there is certainly a cost.

Dr. Rathmell discussed the Postoperative and Opioid-free Anesthesia (POFA) trial, which was prematurely stopped due to side effects of severe bradycardia seen in patients who received high-dose dexmedetomidine. Many opioid-free trials have been plagued by small cohort sizes, variable protocols, and surrogate outcomes. While an opioid-free anesthetic has real value for patients with severe obstructive sleep apnea, or patients with a history of opioid use disorder or severe postoperative nausea, the benefits may not outweigh the risks in low-risk patients. He recommends shifting the focus away from complete elimination of opioids, and toward de-centering them from the anesthetic.

Dr. Rathmell was followed by another panelist, Karim Ladha, MD, MSc, Evelyn Bateman Recipe chair in Ambulatory Anesthesia and Women’s Health at Women’s College Hospital and associate professor at the University of Toronto. Dr. Ladha questioned why we so readily administer opioids, drugs with very high side effect profiles, in the perioperative period. He suggested that there have been several studies demonstrating that for specific operations, such as bariatric surgery, breast surgery, laparoscopic abdominal surgery, and ambulatory orthopedic surgery, an opioid-free anesthetic can be effectively performed through the use of regional anesthesia and/or multimodal analgesics. He argues that while the POFA trial was prematurely paused, it also employed dexmedetomidine as a single drug (and at high doses) to substitute opioids, whereas many surgeries striving for opioid-free anesthesia utilize multiple drugs with varied mechanisms, harnessing individual strengths and trying to minimize adverse effects. He agreed with Dr. Rathmell that opioids should be de-centered, and that more work needs to be done in terms of quantifying efficacy than just reduction of morphine equivalents such as patient-reported pain, functional recovery, postoperative opioid consumption, and patient satisfaction.

The final panelist Cornelius Groenewald, MD, associate professor at Stanford University, started with his punchline: he takes a very different approach than the previous two panelists, and believes every patient should receive a dose of fentanyl prior to surgical incision. He provided data that 30-80% of patients experience acute moderate-to-severe pain following surgery, and that this acute pain can predict the development of postoperative chronic pain. For an opioid-free anesthetic to be superior to an opioid-based anesthetic, it must be safer (i.e., fewer side effects) and also be more effective (i.e., significantly reduce pain scores and minimize postoperative opioid consumption). No randomized clinical trial to date has been effective in demonstrating these findings, though some have confirmed remifentanil-associated hyperalgesia or decreases in postoperative nausea in opioid-free arms. He finished by agreeing that regional anesthesia should be employed where possible, but even in those cases a complete avoidance of opioid-based drugs may not be entirely realistic or effective.