The Direction of the Future: Opioid-Free Protocols

Commentary The research by Turk et al. is a useful addition to the literature, as it allows for the knowledge that, at least in a select population, an orthopaedic surgical procedure can be conducted without the use of opioids, both intraoperatively and postoperatively. The article may be even more useful with regard to additional questions that are raised after a careful evaluation of the results. The first, and perhaps the most important, question is how to identify what patient group is most likely to be successful with an opioid-free protocol. Patients who participated in the study were allowed to self-select whether they wished to participate. Of the 425 patients assessed for eligibility, 35 patients withdrew, with no information given as to why this occurred. As there was a substantial list of exclusion criteria, including the use of chronic opioid therapy and alcohol dependence (both potential risk factors for future opioid dependence), it would be of interest to determine what prompted a patient to withdraw. As brought up by the authors, a concern can be made that there was an element of self-selection bias in the patient cohort. This type of bias is a result of situations in which individuals decide whether or not they wish to participate in the study or remain in it after initiating the planned treatment1. In this case, the patient population may not be representative of an orthopaedic population in general, which may lead to a result that is different from the one that would be found in the target population as a whole. Further research would help to identify the population that will be most successful with the opioid-free treatment. It seems likely that the opioid-free cohort selected in this study is one that would have limited risk associated with the use of opioids during a surgical procedure and immediate postoperative period, particularly in terms of a future substance-use disorder. Further evaluation of the population who did not participate, either by not electing to participate or by withdrawing, may actually be of greater help, as this may be a population at risk for adverse effects, including potential substance dependence, with opioid use. A second question is just how much a composite of procedures provides information in terms of identifying specific procedures that are most likely to be successful when performed with an opioid-free protocol. The hip results are not as robust as those for the other procedures, and no knee results are provided in this or other articles by this group2–4. The authors do state that their results may not translate as well to the individual procedures or to other procedures not included in the study, and further detail should be published for specific surgical procedures such as for the hip and knee before this protocol is attempted in a general orthopaedic population. The authors should be applauded for their initial investigation, and we all look forward to future research that can help orthopaedic surgeons and anesthesiologists by providing greater detail for selecting populations that are most likely to benefit from this protocol, as well as by identifying those who are at greater risk for potential opioid abuse.