Prolonged use of opioids after surgery

Written By: BL Friedberg MD
Date Published: Mon, 2014-03-03
Editorials: Prolonged use of opioids after surgery
BMJ 2014;348:1280

Re: Prolonged use of opioids after surgery

Over the past 16 years using the numerically reproducible paradigm of BIS/EMG monitored propofol ketamine (aka Goldilocks) anesthesia, NONE of >4,000 patients having a wide variety of painful, elective cosmetic surgeries required acute postoperative opioid therapy! (1)

With all respect to my learned colleagues, it is patently clear that postoperative pain is simply a function of intra-operative pain.

Side effect free intra-operative pain has been eliminated by using ‘hypnosis first, then dissociation, followed by injection or incision’ (2) for any surgery that breaches the skin barrier to the outside world of danger.

Injection of local analgesia after general anesthesia has been shown to not be of preemptive value. (3)

Preemptive analgesia CAN readily be obtained with 50 mg ketamine (independent of adult body weight) 3 minutes pre-stimulation. Fifty milligrams of ketamine reliably saturates 98-99% of NMDA receptors in adults. (4)

I challenge my colleagues across the pond to just give this simple paradigm a test. The difference in outcomes is dramatically obvious.


1. Friedberg BL: Cosmetic surgery: Postoperative pain and PONV – dissociative anesthesia reconsidered. Plast Reconstr Surg 2010;125:184e-185e.

2. Friedberg BL: Hypnotic doses of propofol block ketamine induced hallucinations. Plast Reconstr Surg 1993;91:196.

3. Moinche S, Kehlet H, Berg J: A qualitative and quantitative systemic review of preemptive analgesia for postoperative pain relief. Anesthesiol 2002;96:725.

4. Friedberg BL: Propofol-ketamine technique, dissociative anesthesia for office surgery: a five-year review of 1,264 cases. Aesth Plast Surg 1999;23:70-74.