Early Career
  • Barriers to Implementation of Opioid-Free Anesthesia by CRNAs

    Author(s): Morgan Morrow, DNAP, CRNA, Amanda Gibson, DNAP, CRNA, Amy Stein, Ph.D., & Shari Burns, Ed.D., CRNA, Midwestern University

    Four Midwestern University poster authors explored barriers to adoption of newer OFA techniques among their CRNA colleagues and found younger practitioners preferring OFA.


    Opioid utilization has traditionally been the gold standard for pain management. Anesthesia providers have relied heavily on opioids to ensure patient comfort. However, opioid use throughout the perioperative period is associated with complications. Because of these risks, OFA techniques may be considered. While research supporting the use of OFA techniques is becoming more available, it is presently unknown what proportion of CRNAs have adopted OFA. Hypothesized barriers to OFA implementation are a lack of education regarding OFA techniques, a lack of equipment necessary to provide these services, and/or a perceived barrier of facility culture that is resistant to OFA implementation. This research aims to expand the current knowledge of OFA’s perceptions, identify the percentage of surveyed CRNAs who utilize OFA, and identify perceived barriers to OFA.


    A 20-question electronic survey was distributed nationally to CRNAs. The lead author developed the survey tool based on clinical experience, noting barriers to opioid-free anesthesia, and a literature search. The survey was tested as a pilot survey and sent to Arizona CRNAs. Because of the lack of generalized data specific to CRNAs, hypothesized barriers to OFA were left broad. Questions were unchanged from the pilot study. A biostatistician analyzed completed responses. Survey variables were summarized and compared with a Chi-square test. Variables included practice model (independent versus collaborative), highest education level achieved, additional training, exposure to OFA techniques, and availability of materials needed to utilize OFA. Lastly, facility barriers to practice change, attitudes towards education on OFA’s benefits, and overall attitude on OFA were evaluated. Significance was determined by P < 0.05.


    339 were completed responses, reflecting an 11. 7% response. Results that reached statistical significance are demonstrated in Table 1 (below).

    Table of Results from OFA Survey


    The survey’s results demonstrate that CRNAs believe OFA techniques are beneficial, with younger practitioners preferring OFA. Additionally, most CRNAs surveyed utilize PNB techniques as an analgesic method in their practice, but only 38% of survey respondents felt they were competent in administering them. There was a large disparity in perception of competence between genders amongst CRNAs, with males reporting a higher competence. As education emphasizes newer anesthetic techniques, such as OFA and PNBs, novice providers may be more comfortable and familiar with these anesthesia techniques regardless of gender. The perception of competence based on gender was an unintended finding of this survey and will be explored in upcoming research. While many CRNAs believe there is a benefit to OFA, barriers to implementation remain. Since OFA techniques are newly emerging, some providers may not see a benefit in changing their practice. Further research addressing why some CRNAs with less exposure to OFA are hesitant to implement it into their practice may be beneficial. Creating a facility culture wherein OFA techniques are encouraged will promote more widespread adoption of OFA practice. Additional research regarding facility culture and the perception of competence of new anesthetic techniques may help remove additional barriers to OFA implementation.


    Grant support provided by Midwestern University Glendale Office of Research & Sponsored Programs. The authors have declared no financial relationships with any commercial entity related to the content of this article. The authors did not discuss off-label use within the article.

    Presented in AANA Foundation’s “State of the Science” Poster Session.


    Dunn LK, Durieux ME, Nemergut EC, Naik Bl. Surgery-induced opioid dependence: adding fuel to the fire? Anesth Analg. 2017;125(5): 1806-1808. doi: 10.1213/ANE.0000000000002402

    Pearsall EA, Meghji Z, Pitzul KB, et al. A qualitative study to understand the barriers and enablers in implementing an enhanced recovery after surgery program. Ann Surg. 2015;261(1 ):92-96. doi:10.1097/SLA.0000000000000604

    Lyon A, Solomon MJ, Harrison JD. A qualitative study assessing the barriers to implementation of enhanced recovery after surgery. World J Surg. 2014;38(6):1374-1380. doi:10.1007/s00268-013-2441-7

    Velasco D. Barriers and facilitators to intraoperative alternatives to opioids: examining CRNA perspectives and practices. AANA Journal. 2019;87(6): 459-467

    Ost K, Blalock C, Fagan M, Sweeny KM, Miller-Hoover SR. Aligning organizational culture and infrastructure to support evidence-based practice. Critical Care Nurse. 2020; 40(3): 59-63. doi: 10.4037/ccn2020963