What are the recommended opioids for scoliosis surgery?

Recommended Opioids for Scoliosis Surgery

For scoliosis surgery, opioids should be used judiciously as part of a multimodal analgesia regimen, with morphine equivalents via patient-controlled analgesia (PCA) or immediate-release formulations being the standard approach, limited to no more than 7 days postoperatively to minimize risks of chronic use and addiction. 1, 2

Multimodal Analgesia Framework (Opioid-Sparing Strategy)

The foundation of pain management for scoliosis surgery should prioritize non-opioid medications, with opioids reserved for breakthrough pain when other modalities are insufficient. 1, 2

First-Line Non-Opioid Medications

• Pregabalin/Gabapentin: Administer preoperatively and continue postoperatively to significantly reduce opioid consumption and improve long-term functional outcomes 1, 2
• COX-2 Inhibitors or NSAIDs: Use throughout the perioperative period as the analgesic foundation, with short-term use (<2 weeks) appearing safe even after spinal fusion 1, 2
• Acetaminophen: Administer preemptively and continue throughout the perioperative period in combination with NSAIDs for superior analgesia 1, 2
• Dexamethasone: Consider as part of the multimodal approach to reduce inflammation and pain 1

Regional Anesthesia Techniques

• Epidural analgesia: Provides superior pain control with lower pain scores on all three postoperative days (POD1: -15.2 points, POD2: -10.1 points, POD3: -11.5 points on 0-100 scale) and reduces opioid-related side effects 3
• Bilateral bi-level erector spinae plane (ESP) blocks: Novel technique at two levels (e.g., T4 and T10) that enables transition to oral analgesia on postoperative day one with minimal opioid requirements 4
• Local anesthetic wound infiltration: Bupivacaine (conventional or liposomal formulations) can provide immediate to extended relief (up to 96 hours with liposomal preparations) 1

Adjunctive Intraoperative Strategies

• Ketamine infusions: Likely beneficial as part of the multimodal regimen 1
• Dexmedetomidine infusions: Can be incorporated for opioid-sparing effects 4
• Remifentanil considerations: When using remifentanil intraoperatively with epidural analgesia postoperatively, no association exists between intraoperative remifentanil dosage and postoperative opioid consumption 5

Specific Opioid Recommendations

Intraoperative Opioids

• Fentanyl: Intermediate effect-site concentrations (1-2 ng/mL) at time of wake-up testing provide good balance between rapid emergence and adequate analgesia 6
• Remifentanil: Can be used intraoperatively without increasing postoperative opioid requirements when combined with epidural analgesia 5

Postoperative Opioids

• Morphine via PCA: Standard approach for early postoperative period (first 3 days), with dosing adjusted based on patient response 1
• Immediate-release oral opioids: Transition to oral route as soon as possible 1, 7
• Duration limit: Prescribe no more than 5-7 days of opioids total 1, 2
• Avoid modified-release preparations: New prescriptions of long-acting opioids (including transdermal patches) should be avoided without specialist consultation 1

Critical Risk Factors and Preoperative Considerations

High-Risk Patients for Prolonged Opioid Use

Preoperative opioid use is the strongest predictor of chronic postoperative opioid use and worse outcomes. 1

Specific risk factors include:

• Any preoperative opioid use (odds ratio 2.93 for prolonged postoperative use) 8
• Preoperative opioid dosage >30 morphine milligram equivalents (MMEs) 1
• Female sex, obesity, preoperative anxiety diagnosis 8
• Preoperative muscle relaxer prescriptions 8

Protective factors include:

• Fewer fusion levels (compared to ≥13 levels) 8
• Preoperative anxiolytic and antidepressant use 8

Preoperative Optimization

• Identify high-risk patients: Those with mental health comorbidities (depression, substance abuse, antisocial personality disorder) require tailored postoperative pain management 1
• Patient education: Provide realistic expectations about postoperative pain and opioid risks, as patients often underestimate pain severity 1
• Substance abuse screening: If possible, detoxification before surgery decreases risk of uncontrolled postoperative pain and complications 1

Postoperative Monitoring and Discharge

Monitoring Requirements

• Sedation scores: Record alongside respiratory rate to detect opioid-induced ventilatory impairment 1, 7
• Duration threshold: Patients still taking opioids 90 days after surgery warrant medical evaluation for persistent pain or referral to pain/substance misuse services 1

Discharge Prescribing

• Maximum duration: 5-7 days of opioids maximum 1, 2
• Explicit documentation: Discharge letter must state recommended opioid dose, amount supplied, and planned duration 1
• Separate prescriptions: Prescribe opioids and non-opioids separately to allow individual dose adjustments 1
• Patient instructions: Provide clear guidance on safe administration, weaning, and disposal of unused medications 1, 7
• Avoid repeat prescriptions: Postoperative opioids must never be added to repeat prescribing templates 1

Common Pitfalls to Avoid

• Overreliance on opioids alone: Up to 75% of people entering heroin addiction treatment report prescription opioids as their first exposure 1
• Inadequate multimodal approach: Failure to implement non-opioid medications as the foundation leads to excessive opioid consumption 1, 2
• Prolonged prescribing: Prescriptions beyond 7 days significantly increase risk of chronic opioid use 1, 2
• Ignoring preoperative opioid use: Patients with preoperative opioid use have worse 2-year outcomes, higher complications, and lower odds of achieving meaningful improvements in pain, function, and quality of life 1
• Inadequate follow-up: Failure to monitor for persistent opioid use beyond 90 days delays identification of chronic post-surgical pain 1