Author: Jordan Francke, MD, MPH
IARS and SOCCA 2026 Annual Meeting coverage
Opioids remain highly effective for treating severe perioperative pain, but their use is associated with respiratory depression, nausea, ileus, delirium, persistent postoperative use, and opioid-induced hyperalgesia. During the 2026 IARS and SOCCA Annual Meeting, experts debated whether anesthesiologists should pursue completely opioid-free anesthesia or instead focus on carefully reducing opioid exposure.
James Rathmell, MD, MBA, distinguished between opioid-free anesthesia, in which no opioids are administered during the perioperative period, and opioid-sparing anesthesia, in which opioids are deliberately minimized.
Although high-dose opioids have historically provided effective analgesia with relatively stable hemodynamics, approximately 5% to 10% of surgical patients may continue using opioids after surgery. This risk, together with other adverse effects, supports reconsidering the routine placement of opioids at the center of anesthetic care.
Dr. Rathmell reviewed the Postoperative and Opioid-Free Anesthesia trial, which was stopped early because patients receiving high-dose dexmedetomidine experienced severe bradycardia. This illustrates that replacing opioids with another potent medication does not automatically produce a safer anesthetic.
Research on opioid-free anesthesia has also been limited by:
- Small study populations
- Inconsistent medication protocols
- Different surgical procedures
- Reliance on surrogate outcomes
- Inadequate assessment of functional recovery
Opioid-free techniques may be particularly beneficial for patients with severe obstructive sleep apnea, previous opioid use disorder, or severe postoperative nausea and vomiting. However, the risks and complexity of complete opioid avoidance may not be justified for every low-risk patient.
Dr. Rathmell recommended de-centering opioids rather than insisting that they be eliminated universally.
Karim Ladha, MD, MSc, argued that anesthesiologists should question the routine administration of medications with such significant adverse effects. Opioid-free techniques have been used successfully for selected bariatric, breast, laparoscopic abdominal, ambulatory orthopedic, and other surgical procedures.
These approaches commonly combine regional anesthesia with several nonopioid medications rather than relying on a single high-dose substitute. A multimodal regimen may include medications and techniques with different mechanisms of action so that the benefits of each are preserved while individual adverse effects are limited.
Dr. Ladha emphasized that success should not be measured only by reductions in morphine-equivalent dosing. More meaningful outcomes include:
- Patient-reported pain
- Functional recovery
- Opioid consumption after discharge
- Adverse events
- Patient satisfaction
- Quality of recovery
Cornelius Groenewald, MD, presented a contrasting position. He argued that every surgical patient should receive fentanyl before incision because untreated acute pain remains common and may contribute to chronic postsurgical pain.
Between 30% and 80% of patients experience moderate to severe acute postoperative pain. Therefore, an opioid-free technique should not be considered superior unless it both reduces adverse effects and provides better analgesia than an opioid-containing anesthetic.
Available randomized trials have not consistently demonstrated that opioid-free anesthesia improves both safety and pain outcomes. Some studies have shown less postoperative nausea, and others have identified hyperalgesia associated with remifentanil, but the evidence has not established that complete opioid avoidance is broadly superior.
Regional anesthesia should be used whenever appropriate, but even effective blocks may not eliminate the need for opioids in every patient or procedure.
Key Takeaways
Universal opioid-free anesthesia is not currently supported by sufficient evidence and may expose some patients to adverse effects from high doses of alternative medications.
The more realistic goal is to remove opioids from their traditional position as the default foundation of every anesthetic. Opioids should be used selectively, at the lowest effective dose, and as one component of a comprehensive multimodal plan.
Opioid-free anesthesia may be appropriate for selected patients and procedures, particularly when opioid-related risks are unusually high. However, complete avoidance should not become an inflexible standard.
Regional anesthesia and multimodal analgesia should be used whenever they can improve pain control and reduce opioid exposure.
Future research should focus on meaningful patient outcomes rather than opioid consumption alone. Pain relief, functional recovery, complications, patient satisfaction, and opioid use after discharge are more important than whether the intraoperative record contains zero opioids.
The best strategy is individualized care: use opioids when they provide meaningful benefit, minimize unnecessary exposure, and avoid replacing one medication-related risk with another.
Thank you to IARS and SOCCA for allowing us to summarize this important coverage from the 2026 Annual Meeting.