An Emerging Paradigm for Safer and Faster Recovery: A Narrative Review on Opioid Sparing Anesthesia in Surgery

Opioid-free anesthesia (OFA) replaces opioid use with many non-opioid drugs, such as dexmedetomidine, lidocaine, esketamine, regional techniques, and enhanced recovery after surgery (ERAS)-aligned strategies to control pain while minimizing opioid-related adverse effects. Across surgical procedures, we conducted a narrative review of the literature, which showed that OFA is consistently associated with lower postoperative nausea and vomiting, faster recovery of gastrointestinal function, and reduced rescue opioid use, with similar post-anesthesia care unit (PACU) stay and pain scores in many trials. Pediatric and ambulatory settings also show fewer emetogenic symptoms and quicker readiness for discharge. However, evidence quality is mixed: several randomized trials and meta-analyses report meaningful reductions in PONV and opioid consumption but only modest or clinically marginal analgesic gains. Safety signals-particularly with α2-agonists like dexmedetomidine-include intraoperative hypotension/bradycardia and potential prolonged sedation, underscoring the need for careful dosing and patient selection. Contemporary guidance therefore favors opioid-sparing (minimizing rather than eliminating opioids) as a pragmatic interim goal while high-quality trials further define OFA's net benefit, optimal drug combinations, and perioperative extensions (e.g., postoperative low-dose infusions). Future work should refine protocols that de-emphasize routine lidocaine, titrate dexmedetomidine judiciously, and integrate targeted regional blocks to balance recovery benefits with hemodynamic safety, particularly in high-risk populations such as those with obesity or sleep apnea.