Currently, patients in seven states can tell their physicians they don't want to be treated with opioids in any health care setting, even during surgery. While unnecessary opioid exposure is a big reason behind the opioid epidemic in the U.S., we believe that non-opioid directives that allow patients to opt out of opioids in the operating room may lead to unexpected harms.

Non-opioid directives share some common features with advance directives, legally recognized documents that allow patients to list their preferences for what happens at the end of life. Both documents guide care based on the desires of the patient. Non-opioid directives are mandates that a patient must not receive opioids under any circumstances. Exceptions are rare.

Congress is currently considering legislation allowing access to these directives across the nation. While only one of the seven states with non-opioid directives excludes care during surgical procedures, both proposed bills in the House and Senate contain an exclusion specific to care in the operating room.

We are a team of physicians who work with and study the use of opioids in surgical settings. Two of us co-direct the Opioid Prescribing Engagement Network, which develops best practices for opioid prescriptions after surgery. We have seen medical practice shift from embracing opioids to eliminating them altogether. We believe that opioids serve an essential tool in the operating room for many patients, and avoiding them for certain cases can make it difficult if not impossible to avoid harming patients.

The role of opioids in anesthesia

Anesthesia is tailored for each patient depending on the surgical procedure, with the appropriate degree of sedation varying for each case. At one end of the scale is minimal sedation, which usually allows patients to respond to verbal commands. At the other end is general anesthesia, which keeps patients unconscious even during pain. Different medications make this range of sedation possible.

A concept called balanced anesthesia has guided clinicians in how they care for patients in the operating room for more than a century. The goal is to give a patient different types of medications to obtain loss of pain, memory, movement and consciousness while preserving other essential functions of the body.

Relying on only one or two types of medication usually requires higher doses to achieve anesthesia, which can result in bothersome or concerning side effects. Using a combination of drugs, on the other hand, lowers the amount of drug needed to achieve sedation. Because each drug works on a different set of receptors in the body, the desired effects can be attained with smaller doses of each drug than with one drug given alone. This reduces the risk of side effects and leads to more stable vital signs during surgery.

Opioids stand out among the typical sedatives and anesthetics used in the operating room by significantly reducing the amount of other drugs needed to achieve pain relief, sedation and loss of consciousness. Even small doses of opioids are sufficient to activate areas in the brain that decrease the input of pain signals from other areas of the body.

Why the operating room is different

As broader calls to reduce unnecessary opioid use rise, anesthesiology and surgery researchers have asked whether avoiding all opioids in the operating room would lead to better patient outcomes. The first set of published studies on this question suggests that completely eliminating opioids from the operating room may do more harm than good.

In one study, researchers randomly assigned patients who needed general anesthesia for surgery to either a group that received an ultrafast-acting opioid or a non-opioid sedative commonly used in intensive care units. After a surprising number of patients in the non-opioid group experienced serious adverse events during surgery, such as dangerously reduced heart rates and low oxygen blood concentration, the researchers stopped the study early because of safety concerns.

Similarly, a review of studies found that eliminating opioids during surgery did not decrease either patient use of prescription opioids after discharge or provider overprescription of opioids beyond just reducing opioid dosage during the procedure.

Non-opioid directives and the OR

Drug overdoses in the United States continue to reach record numbers, with estimates of more than 107,000 deaths in 2021. How best to use pharmaceutical company lawsuit settlement payouts given to West Virginia and other states has been hotly debated. But we believe that approaches that allow patient to opt out of opioids in the operating room may lead to unsafe care.

Opioids are useful beyond pain reduction and play a role in helping patients safely emerge from general anesthesia. Avoiding opioids may be a safe option when general anesthesia is not needed, such as procedures on the hand, leg or feet that use only nerve blocks to reduce pain. Prescription opioids may also not be needed when patients recover at home after many types of surgery.

Opioids are a tool that can complement a thoughtful anesthetic and surgical plan. Whether or not patients receive opioids during surgery doesn't affect how likely they are to continue using opioids or receive an opioid prescription afterward. We believe that wholesale elimination of opioids without considering the unique setting of the operating room may lead to unintended safety risks for patients. A more nuanced care plan that relies on reduced amounts of opioids could set patients up for a faster recovery with fewer side effects and better outcomes after surgery.

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