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306 L. C. Ong Sio et al.

19. Kohan L, et al. Buprenorphine management in the perioperative period: educational review and

recommendations from a multisociety expert panel. Reg Anesth Pain Med. 2021;46(10):840–

59.

20. Aroke EN, et al. A practical approach to acute postoperative pain management in chronic pain

patients. J Perianesth Nurs. 2020;35(6):564–73.

21. Harrison TKMD, et al. Perioperative considerations for the patient with opioid use

disorder on buprenorphine, methadone, or naltrexone maintenance therapy. Anesthesiol Clin.

2018;36(3):345–59.

22. Ward EN, Quaye AN, Wilens TE. Opioid use disorders: perioperative management of a special

population. Anesth Analg. 2018;127(2):539–47.

23. Jain N, et al. Efﬁcacy of buprenorphine and clonidine in opioid detoxiﬁcation: a hospital- based

study. Indian J Psychiatry. 2018;60(3):292–9.

24. Barreveld AM, et al. Caring for our patients with opioid use disorder in the perioperative period:

a guide for the anesthesiologist. Anesth Analg. 2023;137(3):488–507.

https://t.me/med1917

Perioperative Care

of the Opioid-Tolerant Patient:

A Complimentary Perspectives

Nathan J. Rudin

Abstract Surgical patients who chronically use opioids pose unique challenges for

anesthesia and perioperative pain management. This chapter provides recommen-

dations for optimal perioperative pain care in the opioid-tolerant patient, including

attention to special cases such as patients taking buprenorphine for opioid use disorder

or receiving intrathecal opioids for pain management. Clinicians can maximize safety

and efﬁcacy using a combination of non-opioid medications, regional blocks, and

nonpharmacologic strategies. Treatment should be tailored to the speciﬁc needs of

each patient.

Keywords Surgical anesthesia

· Perioperative · Pain management · Opioids ·

Opioid use disorder · Buprenorphine · Intrathecal drug delivery · Regional

anesthesia

· Tolerance · Dependence

1 Introduction

Clinicians will commonly encounter opioid-tolerant patients who need surgery.

Opioid use for chronic non-cancer pain is declining but still substantial, opioids

remain a primary treatment for cancer-related pain, and the use of illicit opioids is

on the rise. Early identiﬁcation of opioid-tolerant surgical patients is vital to ensure

appropriate care before, during and after surgery.

Treating the opioid-tolerant surgical patient can be challenging. Too much addi-

tional perioperative opioid may increase the risk of morbidity, and postoperative pain

control can be difﬁcult to attain; insufﬁcient perioperative analgesia raises the risk

of other harms. Patients using intrathecal opioids for pain treatment pose special

challenges, as do those with opioid use disorder. The latter, especially if they are

taking opioid agonist-antagonists (usually buprenorphine) for medication-assisted

treatment, may require special measures to mitigate acute opioid withdrawal.

N. J. Rudin (

)

Division of Rehabilitation Medicine, Department of Orthopedics and Rehabilitation, School of

Medicine and Public Health, University of Wisconsin, Madison, WI, USA

e-mail: rudin@rehab.wisc.edu

A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,

https://doi.org/10.1007/978-3-031-67648-2_20

307

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308 N. J. Rudin

In this chapter we synthesize the best available evidence for perioperative

pain management in opioid-tolerant individuals. Thoughtful care planning and

management will result in effective, compassionate, and safe treatment.

2 Opioid Tolerance and Surgery

In practice, perioperative management of the opioid-tolerant patient varies widely

because of competing concerns and preferences.

•

Patients taking chronic opioids may have worse surgical outcomes. Joint arthro-

plasty patients on chronic opioids have lower preoperative function and higher

pain, lower postoperative function and satisfaction [1], longer lengths of stay,

higher revision rates, and higher medical costs [2] than those not taking opioids.

Opioid-tolerant patients were twice as likely to be re-hospitalized following major

abdominal surgery [3], and perioperative opioids were associated with worse

outcomes and higher costs [4]. Preoperative opioid use was associated with a

higher risk of wound infection after multilevel lumbar fusion [5]. In general,

patients on chronic opioids report higher postsurgical pain and demonstrate slower

pain resolution [6]. These concerns have led to recommendations that chronic

opioids be tapered and, where possible, discontinued prior to elective surgery.

•

Aggressive opioid dose reduction may itself lead to signiﬁcant morbidity. Long-

term opioid tolerance may represent a persistent neural adaptation requiring

extended periods to reverse [7]. Rapid tapering can result in uncontrolled pain,

disruptions of sleep and appetite, and the opioid withdrawal syndrome, leading

to an increase in physiological stress [8, 9]. Stressed patients have suboptimal

surgical outcomes [10]. For these reasons, some authorities recommend main-

taining the preoperative opioid dose, or higher if indicated for additional relief,

during the perioperative period [11–13].

Faced with these conﬂicting concerns, the clinician is best served by using

a common-sense, evidence-driven approach to perioperative pain management,

adjusting the treatment plan to meet the needs and circumstances of each patient.

The focus should remain on the primary goal of effective anesthesia and analgesia

with the lowest possible risk and morbidity.

The key principles of perioperative pain management are:

1. Perioperative pain management should be unique for each patient.

2. Where possible, the management plan begins well before surgery.

3. The plan must be ﬂexible enough to change as circumstances demand.

3 Steps for Perioperative Pain Management

1. Perform a thorough perioperative pain evaluation [13–15].

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Perioperative Care of the Opioid-Tolerant Patient: A Complimentary … 309

a. Diagnose pain conditions. Understand causes of pain both related and

unrelated to the planned surgery.

b. Understand the patient’s preoperative medication regimen and stratify risk.

Ascertain doses of opioids and other medications, as well as drug allergies/

intolerances. Risk stratiﬁcation method schemes include the Perioperative

Quality Initiative (POQI)’s “O-NET+” [15], the ORBIT instrument [16] and

the RIOSORD scale [17].

c. Determine psychological comorbidities which may affect the patient’s ability

to cope with surgery and changes to the regimen.

d. Understand the patient’s support network. Educating family and caregivers

can improve adoption of and adherence to pain care goals.

e. Solicit the patient’s concerns and questions about surgery and pain manage-

ment.

2. Educate the patient and family before surgery. Education ideally takes place

well before the day of surgery, often during a preoperative evaluation visit [14,

18].

a. Explain the surgery thoroughly as per standard informed consent methods.

b. Deﬁne perioperative pain management goals and explain available pain care

tools. A thorough understanding of the pain care plan mitigates anxiety while

helping patients and families plan ahead before surgery occurs.

c. Elicit agreement on pain management goals and medication plan. Achieving

shared expectations and patient buy-in before surgery facilitates better pain

care and improves outcomes.

a. Aim for a minimum effective dose rather than opioid cessation. Lower preop-

erative opioid doses are preferable, especially for patients on higher doses,

to minimize potential morbidity. However, the approach to opioid dosing

must be individualized to the patient. Routine preoperative opioid tapering,

especially to zero, without appropriate alternative treatment is not recom-

mended [19, 20]. While a zero preoperative opioid dose may be desirable, it

is not necessarily realistic or achievable; in many individuals it is necessary

to settle for the lowest possible dose that still preserves comfort and function.

Flexibility in the optimization plan is therefore required.

b. Combine opioid weaning with non-opioid strategies. Careful preoperative

opioid reduction can be accomplished given adequate time, use of behavioral

and non-opioid techniques (leveraging the biopsychosocial model of pain),

and clear establishment of expectations. For individuals with a higher risk

of opioid-related adverse events, consider consulting a pain specialist for

assistance with the pain care plan. Multidisciplinary centers for perioperative

pain management, when available, provide ideal environments for successful

preoperative opioid reduction [20, 21].

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310 N. J. Rudin

c. Make and share a plan for postoperative management. If the planned surgery

is intended to address the pain condition being treated with opioids, a post-

operative opioid tapering plan should be discussed and outlined before

surgery.

3. Optimize mood and coping skills where needed. Individuals at higher risk for

opioid-related morbidity can receive mindfulness-based or other stress manage-

ment training before surgery to enhance pain coping; if in-person sessions are

not available, extensive resources are available on websites and smartphone

applications. Group-based or individual health psychology interventions can also

improve and strengthen pain coping skills. Psychiatric evaluation and treatment,

and broader psychotherapy, may be necessary for patients in severe emotional

distress [15, 22]. Preoperative (“prehabilitation”) programs incorporating stress

reduction are associated with signiﬁcant surgical cost savings and improved

outcomes [10].

4. Individualize the treatment plan, using non-opioid and low-opioid strate-

gies where possible. The primary goal of treatment is achievement of effective

anesthesia and analgesia with minimal risk and morbidity. A rational prescribing

approach, using multimodal anesthesia and analgesia, is paramount [22].

a. Make sure pain is controlled. Reduction of opioids must not be allowed

to result in undertreatment of perioperative pain, which is associated

with delirium, surgical and cardiopulmonary complications, deconditioning,

development of chronic pain, relapse in patients with substance abuse

disorders, and reduced quality of life [19].

b. Maintain preoperative opioid dose. For those who continue to take opioids

preoperatively, the immediate preoperative daily opioid dose (or its equivalent

in potency) should be maintained during surgery and early recovery. Opioid

withdrawal must not be allowed to occur.

c. Use non-opioid agents where possible. Non-opioid agents should be used

during anesthesia and for postoperative anesthesia. Where postoperative

opioids are required, the minimum effective dose should be used to minimize

the risk of opioid-induced hyperalgesia[23] or other adverse events.

d. Limit postoperative opioids to the minimum necessary. Patients should be

transitioned to non-opioid analgesics as soon as possible after surgery.

Opioid-tolerant patients should be rapidly returned to their preoperative base-

line opioid dose. When surgery is intended to address the pain condition being

treated with opioids, postoperative tapering can begin once surgical recovery

is well underway.

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Perioperative Care of the Opioid-Tolerant Patient: A Complimentary … 311

4 Opioid-Sparing Anesthesia and Analgesia Techniques

Numerous non-opioid agents are available for intraoperative and postoperative use.

They can be quite useful, both alone and in combination, for anesthesia and pain

management. They must be used cautiously, as all have signiﬁcant potential for side

effects and drug-drug interactions, and all have therapeutic ceilings [24]. Deﬁnitive

combinations and dosages of these agents in multimodal anesthesia have not yet been

determined, but the skilled anesthesiologist can apply these agents judiciously, with

or without opioids, to provide satisfactory anesthesia and effective postoperative pain

control [25–29].

Fully opioid-free anesthesia (OFA) is a desirable goal in the opioid-tolerant

patient, but the science of OFA remains in its early stages. Currently available

evidence for OFA is of variable quality. The best available meta-analyses suggest

that OFA is not inferior to regimens which include opioids [22], but which patients

and surgeries are most suitable for OFA has not yet been determined.

We here brieﬂy summarize common non-opioid agents for perioperative pain

management. The choice of agent must be individualized, taking patient-speciﬁc

variables into account. The reader is directed to the growing literature on opioid-

sparing and opioid-free anesthesia for the latest evidence and recommendations.

a. Preoperative regional and local anesthetic techniques reduce intraoperative

and postoperative opioid use [30]. Targeted regional nerve blocks, epidural anes-

thetics, perineural catheters, and/or anesthetic inﬁltration at incision sites can

signiﬁcantly reduce postoperative pain.

b. Nonsteroidal anti-inﬂammatory drugs (NSAIDs) maybeusefulinsomeperi-

operative settings, especially given the putative role of the cyclooxygenase-2

(COX-2) enzyme in central nociceptive processing [31]. Limited preoperative

use of COX-2 inhibiting NSAIDs reduces opioid need in patients undergoing

total knee arthroplasty [32] and spinal fusion [24]. Conventional non-selective

NSAIDs can reduce postoperative opioid requirements [33]. Some authorities

advise against the routine preoperative use of a COX-2 inhibitor [34]. Recent

large studies show no increased risk of postoperative hemorrhage or renal injury

with the judicious perioperative use of NSAIDs [35].

c. Propofol is a common and effective non-opioid agent for anesthesia induc-

tion and maintenance and is a valuable tool for anesthesia where patients are

at elevated risk for opioid-related adverse events [36].

d. Dexmedetomidine is an adrenergic alpha-2

agonist with sedative and mild

analgesic effects and is commonly employed for procedural sedation. It is a

key element of many OFA regimens, which show promise for better quality of

recovery and fewer side effects in multiple surgical settings [37–40].

e. Ketamine has proven efﬁcacy in acute pain care. Subanesthetic ketamine infu-

sions may be helpful perioperatively in opioid-tolerant patients [41]. Evidence

that ketamine decreases perioperative opioid use is limited. It may work best for

this purpose in opioid-tolerant patients [42].

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312 N. J. Rudin

f. Intravenous lidocaine signiﬁcantly reduces postoperative pain in multiple

settings [43], and may reduce postoperative opioid need [44]. It may reduce

persistent postsurgical pain, but evidence is limited [45, 46]. Topical lidocaine

patches may be helpful for the treatment of cutaneous dysesthesia but are not

effective for acute wound pain management [47].

g. Gabapentin and pregabalin are commonly used perioperatively to reduce post-

surgical pain and opioid use. There is evidence for decreased analgesic use

when gabapentin is administered preoperatively [48], but the effect is modest;

gabapentin may promote postoperative opioid cessation [49]. Perioperative

pregabalin can reduce opioid use but is associated with signiﬁcant sedation [50].

The safety of these drugs is decreased when coadministered with opioids, as the

combination increases the risk of respiratory depression and death, likely through

reversal of respiratory tolerance to opioids [51].

h. Acetaminophen is now available intravenously, though this dosage form is

expensive relative to oral/rectal formulations. Perioperative IV acetaminophen

reduces opioid use after lumbar disc surgery [52] and pancreaticoduodenectomy

[53] but not after hip fracture [54].

i. Other agents employed to reduce or avoid perioperative opioid administration

include corticosteroids, magnesium and beta-blockers.

5 Special Case: Patients Using Buprenorphine

Buprenorphine is a partial μ-opioid receptor agonist and a κ and  receptor antag-

onist. It has high afﬁnity for the μ opioid receptor with slow dissociation. High

doses of conventional opioids are required to displace buprenorphine from the μ

receptor. Buprenorphine use poses unique challenges to perioperative management

of the opioid-tolerant patient.

Buprenorphine is frequently prescribed in oral or sublingual form for the treat-

ment of opioid use disorder, and occasionally for chronic pain (or where opioid use

disorder and pain coexist). Transdermal preparations are available at considerably

lower potency for the treatment of chronic pain. Transdermal buprenorphine does

not signiﬁcantly interfere with perioperative pain management [55], but higher-dose

buprenorphine results in a high perioperative opioid requirement to compete with

buprenorphine’s binding to the μ receptor.

For patients taking buprenorphine for opioid use disorder, current evidence argues

for perioperatively maintaining patients on the regular home buprenorphine dose to

reduce the risk of postoperative relapse into opioid abuse [56]. Non-opioid drugs and

regional anesthetic techniques should be maximized. Dose reduction is not generally

necessary; reduction to 16 mg/d or below before surgery may be helpful if post-

operative need for opioids is anticipated [57]. Where opioids are required to treat

moderate to severe postoperative pain, short-acting opioids with high afﬁnity for the

μ receptor (usually hydromorphone) should be employed under close monitoring,

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Perioperative Care of the Opioid-Tolerant Patient: A Complimentary … 313

and consulting the hospital’s acute pain service is recommended. Close postoperative

follow-up with the buprenorphine prescriber is vital [55].

6 Special Case: Patients with Intrathecal Opioid Delivery

Systems

Implanted intrathecal drug delivery pumps may be used to deliver opioid analgesics

for the treatment of chronic cancer or noncancer pain. Advantages of intrathecal

delivery include targeting of the painful body region by intrathecal catheter posi-

tioning, the ability to use low drug concentrations and thus minimize systemic side

effects, and automation of dosing. Other medications commonly used in intrathecal

pumps include baclofen (for spasticity management), clonidine and bupivacaine (for

analgesia), and ziconotide (for treatment of neuropathic pain). I nterrogation of a

programmable intrathecal pump is relatively simple, but pump programming and

changing the intrathecal drug require experienced personnel.

Evidence is limited, but for patients receiving intrathecal opioids, it appears that in

most circumstances, the clinician can maintain the baseline intrathecal drug regimen

unchanged. Case reports have documented the successful perioperative use of stan-

dard patient-controlled analgesia, epidural anesthesia, and oral opioid regimens in

individuals using intrathecal opioids [58]. In one cohort study, surgical patients on

intrathecal opioids had identical outcomes to matched controls but did require more

opioid postoperatively, suggesting tolerance [59]. Evidence regarding the effects of

other intrathecal agents on surgical anesthesia is lacking.

Abrupt cessation of an intrathecal drug regimen can cause severe complications.

If a pump contains clonidine and/or baclofen, abrupt discontinuation can result in

life-threatening symptoms. Pain specialist consultation is recommended whenever

concerns about intrathecal therapy arise.

7 Conclusion

With thoughtful, individualized and multimodal care, opioid-tolerant patients can

be taken safely through surgery while effectively managing their pain. We have

herein summarized best practices, tools and techniques to help clinicians and patients

achieve this goal.

Key Takeaways

1. Safe, effective, and compassionate perioperative pain management is possible

for opioid-tolerant patients and should be considered the standard of care.

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314 N. J. Rudin

2. Effective management requires comprehensive patient evaluation, preoperative

education and goal setting. Baseline opioid doses should be reduced where

possible but do not insist on a zero dose for all patients.

3. Use non-opioid and opioid-sparing techniques wherever possible during and after

surgery.

4. Limit postoperative opioids to the minimum necessary.

References

1. Morris BJ, Sciascia AD, Jacobs CA, Edwards TB. Preoperative opioid use associated with worse

outcomes after anatomic shoulder arthroplasty. J Shoulder Elbow Surg. 2016;25:619–23.

2. Blevins Peratikos M, Weeks HL, Pisansky AJB, Yong RJ, Stringer EA. Effect of preoperative

opioid use on adverse outcomes, medical spending, and persistent opioid use following elective

total joint arthroplasty in the United States: a large retrospective cohort study of administrative

claims data. Pain Med. 2020;21:521–31.

3. Owodunni OP, Zaman MH, Ighani M, et al. Opioid tolerance impacts compliance with enhanced

recovery pathway after major abdominal surgery. Surgery. 2019;166:1055–60.

4. Cron DC, Englesbe MJ, Bolton CJ, et al. Preoperative opioid use is independently asso-

ciated with increased costs and worse outcomes after major abdominal surgery. Ann Surg.

2017;265:695–701.

5. Pirkle S, Reddy S, Bhattacharjee S, Shi LL, Lee MJ. Chronic opioid use is associated with

surgical site infection after lumbar fusion. Spine (Phila Pa 1976). 2020;45:837–42.

6. Chapman CR, Davis J, Donaldson GW, Naylor J, Winchester D. Postoperative pain trajectories

in chronic pain patients undergoing surgery: the effects of chronic opioid pharmacotherapy on

acute pain. J Pain. 2011;12:1240–6.

7. Mitra S, Sinatra RS. Perioperative management of acute pain in the opioid-dependent patient.

Anesthesiology. 2004;101:212–27.

8. Joshi GP, Ogunnaike BO. Consequences of inadequate postoperative pain relief and chronic

persistent postoperative pain. Anesthesiol Clin North Am. 2005;23:21–36.

9. Mark TL, Parish W. Opioid medication discontinuation and risk of adverse opioid-related

health care events. J Subst Abuse Treat. 2019;103:58–63.

10. Howard R, Yin YS, McCandless L, Wang S, Englesbe M, Machado-Aranda D. Taking control

of your surgery: impact of a prehabilitation program on major abdominal surgery. J Am Coll

Surg. 2019;228:72–80.

11. Grancaric N, Lee W, Scanlon M. Postoperative analgesia in the chronic pain patient.

Otolaryngol Clin North Am. 2020;53:843–52.

12. Group AMD. Prescribing opioids for postoperative pain—supplemental guidance. 2018. Avail-

able from: https://www.agencymeddirectors.wa.gov/Files/FinalSupBreeAMDGPostopPain0

91318wcover.pdf.

13. Dykstra KM. Perioperative pain management in the opioid-tolerant patient with chronic pain:

an evidence-based practice project. J Perianesth Nurs. 2012;27:385–92.

14. Devin CJ, Lee DS, Armaghani SJ, et al. Approach to pain management in chronic opioid users

undergoing orthopaedic surgery. J Am Acad Orthop Surg. 2014;22:614–22.

15. Edwards DA, Hedrick TL, Jayaram J, et al. American society for enhanced recovery and peri-

operative quality initiative joint consensus statement on perioperative management of patients

on preoperative opioid therapy. Anesth Analg. 2019;129:553–66.

16. Larance B, Bruno R, Lintzeris N, et al. Development of a brief tool for monitoring aberrant

behaviours among patients receiving long-term opioid therapy: the opioid-related behaviours

in treatment (ORBIT) scale. Drug Alcohol Depend. 2016;159:42–52.

https://t.me/med1917

Perioperative Care of the Opioid-Tolerant Patient: A Complimentary … 315

17. Zedler BK, Saunders WB, Joyce AR, Vick CC, Murrelle EL. Validation of a screening risk index

for serious prescription opioid-induced respiratory depression or overdose in a US commercial

health plan claims database. Pain Med. 2018;19:68–78.

18. Doan LV, Blitz J. Preoperative assessment and management of patients with pain and anxiety

disorders. Curr Anesthesiol Rep. 2020;10:28–34.

19. Dickerson DM, Mariano ER, Szokol JW et al. Multiorganizational consensus to deﬁne guiding

principles for perioperative pain management in patients with chronic pain, preoperative opioid

tolerance, or substance use disorder. Reg Anesth Pain Med. 2023;rapm-2023.

20. McAnally H. Rationale for and approach to preoperative opioid weaning: a preoperative

optimization protocol. Perioper Med (London). 2017;6:19.

21. Gulur P, Nelli AH. The opioid-tolerant patient: opioid optimization. J Arthroplasty.

2020;35:S50–2.

22. Adams TJ, Aljohani DM, Forget P. Perioperative opioids: a narrative review contextualising

new avenues to i mprove prescribing. Br J Anaesth. 2023S0007-0912(23)00124.

23. Colvin LA, Bull F, Hales TG. Perioperative opioid analgesia-when is enough too much? A

review of opioid-induced tolerance and hyperalgesia. Lancet. 2019;393:1558–68.

24. Shanthanna H, Ladha KS, Kehlet H, Joshi GP. Perioperative opioid administration. Anesthe-

siology. 2021;134:645–59.

25. Eisenbraun A, Schroeder D, Schaff HV, Martin E, Wittwer ED. Single-center retrospective

comparison of opioid-based and multimodal analgesic regimens in adult cardiac surgery. J

Cardiothorac Vasc Anesth. 2023S1053-0770(23)00168.

26. Haffner M, Saiz AM, Nathe R, et al. Preoperative multimodal analgesia decreases 24-hour

postoperative narcotic consumption in elective spinal fusion patients. Spine J. 2019;19:1753–

63.

27. Nassif GJ, Miller TE. Evolving the management of acute perioperative pain towards opioid

free protocols: a narrative review. Curr Med Res Opin. 2019;35:2129–36.

28. O’Neill A, Lirk P. Multimodal analgesia. Anesthesiol Clin. 2022;40:455–68.

29. Stone A, Roberts A, de Boer HD, Kaye AD, Fawcett WJ, Urman RD. Recommendations

for managing opioid-tolerant surgical patients within enhanced recovery pathways. Curr Pain

Headache Rep. 2020;24:28.

30. Cardwell TW, Zabala V, Mineo J, Ochner CN. The effects of perioperative peripheral nerve

blocks on peri- and postoperative opioid use and pain management. Am Surg. 2022;88:2842–50.

31. Martin F, Fletcher D, Chauvin M, Bouhassira D. Constitutive cyclooxygenase-2 is involved in

central nociceptive processes in humans. Anesthesiology. 2007;106:1013–8.

32. Buvanendran A, Kroin JS, Tuman KJ, et al. Effects of perioperative administration of a selec-

tive cyclooxygenase 2 inhibitor on pain management and recovery of function after knee

replacement: a randomized controlled trial. JAMA. 2003;290:2411–8.

33. Martinez L, Ekman E, Nakhla N. Perioperative opioid-sparing strategies: utility of conventional

NSAIDs in adults. Clin Ther. 2019;41:2612–28.

34. Joshi GP. Rational multimodal analgesia for perioperative pain management. Curr Pain

Headache Rep. 2023

35. Warinner C, Parker LF, Shapiro F, Jowett N. Evidence-based perioperative opioid-sparing

techniques during the United States opioid crisis. Curr Opin Otolaryngol Head Neck Surg.

2023;31:231–7.

36. Ameiro RJ, Neves SS, Oliveira RP, Marques BB, Ferreira PC. Perioperative challenges of

heroin addiction: a case report of opioid-free anesthesia in tongue carcinoma excision with

free-ﬂap reconstruction. Cureus. 2023;15: e41195.

37. Choi H, Song JY, Oh EJ, Chae MS, Yu S, Moon YE. The effect of opioid-free anesthesia on

the quality of recovery after gynecological laparoscopy: a prospective randomized controlled

trial. J Pain Res. 2022;15:2197–209.

38. Zhou F, Cui Y, Cao L, Opioid-Free AWG. The effect of opioid-free anaesthesia on the quality

of recovery after endoscopic sinus surgery: a multicentre randomised controlled trial. Eur J

Anaesthesiol. 2023;40:542–51.

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