Perioperative Opioids - Reclaiming Lost Ground

Opium (poppy tears) has been in use since 3400 BCE, with historical writings recording its sedative, euphoric, and analgesic properties, but it was not until the 19th century that morphine was isolated, paving the way for its therapeutic use. The 20th century witnessed advances in pharmacology and molecular biology, leading to the development of many different types of opioids and the recognition and classification of opioid receptors.Analgesia is fundamental to recovery from surgery, and while opioids continue to be the cornerstone of perioperative analgesia, overreliance on these agents and their many adverse effects has led to a reevaluation of their role in modern perioperative practice. Persistent postoperative opioid use (with disordered substance use at the extreme end of the spectrum) and opioid-induced ventilatory impairment have led to a global opioid crisis that has resulted in more than 100?000 deaths per annum worldwide, a number that rises yearly.1 Persistent postoperative opioid use and opioid-induced ventilatory impairment are exacerbated by other factors, such as nonmedical opioid use and opioid diversion. While the numbers of deaths are clearly not on the scale of the current COVID-19 pandemic, regrettably, there are few signs of measures that will force mortality to recede in the near future. In addition, the financial costs for increased health care and substance use disorder treatment, lost productivity, and criminal justice interventions ran to $150 billion in the US alone in 2015.1 While the opioid epidemic may have originated in the US, it has spread to other areas of the world, with Europe having more than 1.3 million individuals with high-risk opioid use.1 Besides the modifiable risk factors (Box),2 indiscriminate use of opioids has also been fueled by aggressive marketing strategies by pharmaceutical companies and the erroneous impression that consumption of opioids for pain does not lead to substance use disorders