Opioids remain the “gold standard” and mainstay for perioperative pain management due to their efficacy, accessibility, familiarity and wide range of formulations available to providers. Despite liberal use of opioids perioperatively, 80 percent of patients who undergo surgery report postoperative pain, with the majority of them reporting it as moderate, severe or extreme.

Opioids as a class of medication have achieved notoriety for their well-recognized limitations, including a narrow therapeutic window, adverse effects, potential for abuse and the resulting major social issues that have blossomed within the last decade. Neuroadaptation has been recognized as a common phenomenon in response to the use of opioids. The resulting clinical conditions include opioid tolerance (OT) and opioid-induced hyperalgesia (OIH). These conditions share some features and can be easily confused but do each have their own distinctive characteristics and proposed mechanisms as outlined in Table 1.

A recent review of OT by...

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