Background/Objectives: Opioid-free anesthesia (OFA) has emerged as a potential alternative to opioid-based anesthesia (OBA) to reduce opioid-related adverse effects. This meta-analysis compares OFA and OBA with respect to postoperative pain and opioid consumption. Methods: PubMed, Cochrane, and Embase libraries were searched for OFA studies published through 12 June 2025. Randomized controlled trials (RCTs) conducted on adult humans were selected; observational studies, studies including neuraxial anesthesia, and RCTs currently awaiting approval were excluded. A forest plot was used to summarize findings of a random-effects meta-analysis to compare OFA (treatment) and OBA (control). Results: Of 1446 citations found, twenty-nine articles met our inclusion criteria. Twenty-six studies reported pain scores with a 0–10 scale. OFA was associated with lower postoperative pain scores (Hedges’ g = –0.34; 95% CI –0.55 to –0.13; p < 0.001; I² = 84%) but with high heterogeneity, limiting clinical significance or strong interpretation of results. Eleven trials were analyzed for opioid use, showing a small reduction with OFA (Hedges’ g = –0.55; 95% CI –1.10 to –0.005; p = 0.048; I² = 96.22%). Subgroup outcomes favored OFA, with an overall reduction in pain found specifically in endoscopic abdominal surgeries. Some secondary outcomes also indicated potential improved recovery profiles through OFA for certain surgeries. Conclusions: OFA was associated with statistically significant lower postoperative pain scores, along with opioid consumption, but with a small effect size and high heterogeneity when compared to OBA. This is potentially comparable in pain control and opioid consumption with limited clinical significance. Overall, outcomes support the continued controlled study of OFA as an alternative to conventional analgesia.

Background: Buprenorphine use in the intensive care unit (ICU) remains not well studied despite growing perioperative guidance supporting its continuation and initiation for patients with opioid use disorder (OUD). Trauma ICU admissions represent a critical opportunity to address untreated OUD, as well as continuation of an already established treatment plan for OUD, yet barriers limit its adoption in this setting. Methods: This single-center quality improvement study evaluated for inpatient buprenorphine prescribing patterns following provider education at a tertiary academic trauma center. Adult trauma ICU patients with OUD admitted between 2016–2024 were identified through the institutional trauma registry. Patients with pre-admission buprenorphine were excluded, yielding a cohort of 95 patients: 24 buprenorphine-exposed (initiated in the hospital) and 71 controls. Primary outcomes included pain scores and opioid requirements (morphine milligram equivalents, MME) during the first 48 hours. Secondary outcomes included hospital length of stay (LOS), discharge disposition, and 90-day readmission. Results: Baseline characteristics were similar between groups. No statistically significant differences were observed in first recorded pain scores (median 8 vs. 10; p=0.35), mean 48-hour pain scores (7.40 vs. 7.76; p=0.44), or total opioid consumption (232 vs. 119 mg MME; p=0.45). Median hospital LOS (16 vs. 19 days; p=0.48) and 90-day readmission rates (42.3% vs. 33.3%; p=0.40) were also comparable. Conclusion: Inpatient buprenorphine initiation in trauma ICU patients with OUD was not associated with worse pain control, increased opioid requirements, or adverse clinical outcomes. These findings support the integration of buprenorphine into critical care pathways as a safe strategy to address OUD during hospitalization and improve long-term recovery continuity.