to balance what patients need for the smoothest possible post-op dis-
charge with your own facility's pharmacological limitations. "Each facility
has its own formulary and list of medications they will or won't carry, and
providers are limited by that," says Dr. Choice.
In the end, it's the combination of drugs that wouldn't be nearly
as effective on their own that makes the difference. "The reason
we're giving all of these agents is to try and get as much analgesic
control as we can while also minimizing or eliminating the admin-
istration of opioids," says Dr. Choice.
No more opioids?
Opioid-sparing techniques are far and away the most conventional
school of thought in current pain control practices, but some
providers insist you can do away with opioids altogether. Barry L.
Friedberg, MD, a Newport Beach, Ca.-based anesthesiologist and the
president and founder of the Goldilocks Foundation (goldilocksfoun-
dation.org), a nonprofit that advocates for brain monitoring while
patients are under anesthesia, has been practicing opioid-free anesthe-
sia (OFA) since 1992.
The technique Dr. Friedberg developed and swears by — a combina-
tion of propofol-ketamine used in conjunction with real-time elec-
tromyography (EMG) and Bispectral Index (BIS) brain monitoring
that measures hypnosis levels and the absence of EMG spikes — not
only eliminates the need for opioids in the periop phase, it also greatly
reduces the need in post-op and decreases the "brain fog" or post-op
delirium that affects about 40% of patients. Plus, he says, it virtually
eliminates PONV, which is a known side effect of opioids for many
patients.
The problem, according to Dr. Friedberg, is the pain the patient
experiences during the surgery itself. This pain is something that opi-
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