As the U.S. continues to confront an opioid epidemic, anesthesiologists and perioperative care teams—including CRNAs and PACU nurses—occupy a key role in the shift toward safer, evidence-based pain management. From OR decision-making to post-discharge tapering, anesthesiology can have a significant impact in minimizing opioid exposure, with guidelines and practice needing to adapt to trends as the crisis evolves.

The opioid crisis remains a major public health emergency. Over the past two decades, it has unfolded in three waves: the first, in the 1990s, was driven by the overprescription of opioids like oxycodone and hydrocodone.1 The second involved a rise in heroin use around 20101. The current third wave is fueled by fentanyl, which is now implicated in most opioid-related deaths.2 In 2022 alone, over 80,000 Americans died from opioid overdoses.3

For many, surgery is a first point of opioid exposure. Research shows that up to 6% of opioid-naïve patients develop persistent use after surgery.4 Even brief prescriptions can lead to dependency, especially in high-risk individuals. On the other hand, opioid analgesics continue to be necessary in the field of anesthesiology even amidst the ongoing crisis due to their potent pain-relieving effects.

To reduce the use of opioids and the risk of opioid dependency, Enhanced Recovery After Surgery (ERAS) protocols have become the standard in many institutions.5 These protocols emphasize opioid-sparing strategies such as regional anesthesia, non-opioid medications, and preoperative education. They require coordination across surgical, anesthetic, and nursing teams.6

One key evolution in perioperative care with positive impacts on the public has been driven by anesthesiology and surgery shifting toward conservative opioid use, particularly after outpatient procedures. Roth et al. highlight the value of individualized tapering plans and early identification of patients at risk for long-term use.7 This includes the use of multimodal analgesia, regional techniques, and patient counseling on pain expectations.

Nurses are essential in this model, often serving as the first to detect poor pain control, delayed weaning, or over-sedation.8 Their communication with anesthesiologists is vital to refining postoperative plans and ensuring safe recovery.

Innovations in pharmacology may further support opioid-free recovery. Brooks et al. (2025) describe a new class of sodium channel-selective analgesics that target pain-transmitting neurons without impairing motor function.9 These agents may offer extended pain relief following surgery, which is particularly useful in outpatient cases where follow-up is limited and the risk of overprescribing is higher.9

Although opioid prescribing has declined, fentanyl’s spread and the lack of universal guidelines for opioid tapering remain challenges.10 Addressing these gaps requires leadership not only from anesthesiologists but also from CRNAs, nurses, and surgical teams working together. The future of surgical pain care depends not just on prescribing less, but on prescribing smarter—through personalized plans, innovative tools, and coordinated care from pre-op to discharge.

References

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2. O’Donnell JK, Gladden RM, Mattson CL, et al. Deaths involving fentanyl, fentanyl analogs, and U-47700—10 states, July–December 2016. MMWR Morb Mortal Wkly Rep. 2017;66(43):1197–1202. doi:10.15585/mmwr.mm6643e1
3. Federal Communications Commission (FCC). Focus on opioids. Connect2HealthFCC. Updated June 6, 2023. Accessed June 12, 2025. https://www.fcc.gov/reports-research/maps/connect2health/focus-on-opioids.html
4. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504
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8. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey. Curr Med Res Opin. 2014;30(1):149-160. doi:10.1185/03007995.2013.860019
9. Brooks EB, Hameed MQ, Zhang Y, et al. Efficacy of sodium channel–selective analgesics for postoperative pain: clinical potential and translational outlook. Pain Med. 2025;26(2):191–202.
10. Schwenk ES, Viscusi ER, Buvanendran A, et al. Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the American Society of Regional Anesthesia and Pain Medicine. Reg Anesth Pain Med. 2018;43(5):456-466. doi:10.1097/AAP.0000000000000806