Anesthesiology. 2021 Apr 1;134(4):645-659. doi: 10.1097/ALN.0000000000003572.
Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms.
阿片类药物是全身麻醉和围手术期镇痛的重要组成部分。出院时开具阿片类药物处方被认为是导致阿片类药物持续使用和滥用的一个因素。与此同时，人们越来越热衷于提倡无阿片类药物策略，其中包括联合使用已知的镇痛药和佐剂，其中许多是以持续输注的形式存在。本文批判性地回顾了围手术期阿片类药物的使用情况，特别是在阿片类药物节约与无阿片类药物策略方面。数据表明，无阿片类药物策略，尽管其出发点崇高，但并没有充分认识到现有证据和临床实践考虑方面的局限性和差距。此外，这些策略不允许根据患者的需求进行镇痛滴定；不清楚最佳成分及其在不同手术环境和围手术期阶段的作用；也不能降低持续使用阿片类药物的风险，从而使我们无法优化疼痛管理并最大限度地减少长期的实际危害。
