Opioid treatment, especially in the intraoperative phase of surgery, can cause a lot of unnecessary side effects. Patients have come back with postoperative pain because of opioids like fentanyl. But is it even possible to have opioid-free anesthesia? Yes, and it does exist. Opioid-free anesthesia offers better outcomes without the side effects of respiratory depression or postoperative nausea.
Join Jenny Finnell as she talks to the clinical coordinator and chief obstetric CRNA of Commonwealth Anesthesia, Dr. Thomas Baribeault, DNP, CRNA. Dr. Thomas Baribeault is also the founder of The Society for Opioid-Free Anesthesia (SOFA). Learn what opioid-free anesthesia is and why it’s beneficial. Discover why it’s recommended to learn and try different methods of doing things. Start understanding how you can bypass those negative side effects that opioids give today!
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What Is Opioid-Free Anesthesia? With Dr. Thomas Baribeault, DNP, CRNA
How do you provide an opioid-free anesthetic? That is what we are going to talk about in our episode with our special guest, Tom Baribeault. Tom is a Clinical Coordinator and Chief Obstetric CRNA for Commonwealth Anesthesia in Lexington, Kentucky. He specializes in obstetric anesthesia, acute surgical pain management, non-surgical pain management, and point-of-care ultrasound.
He founded the Society for Opioid-free Anesthesia, also known as SOFA, which is a nonprofit organization dedicated to education and research on opioid-free anesthesia and post-operative pain management. He received his Bachelor’s degree in Nursing from the Ohio State University, a Master’s degree in Nursing and Anesthesia Residency from Case Western Reserve University and a Doctorate in Nursing Practice and Pain Management Fellowship from the University of South Florida. Welcome, Tom, to the show.
Thanks for having me.
Fellow Ohioan, I always love to meet fellow Bucks. We are going to get into our episode, and the first thing I would love to gather from you is how did you get into this? Did you always know that you wanted to provide opioid-free anesthesia techniques?
No. Starting out, I didn’t even know that was a thing. It’s very similar to yours. We were talking before we started this episode. We were very close to each other our whole careers geographically. The standard anesthetic technique was, 1) Fentanyl on induction and 2) With emergence, we gave Tylenol and Toradol and called that Multimodal Anesthesia. That was the standard when we did heart. It was 20 fentanyl on induction, and you worked in another 10 to 20 through the case as their pressure supported it, and you took them to the ICU intubated. That was very much the culture I was raised in.
We did some peripheral nerve blocks, which are the very basics for orthopedic surgery. Your popliteal, your interscalene, and some axillary blocks for hand surgery. They still probably got 2 reverse and 100 fentanyl when you were put in the block, and then they would go back to the OR and get another 100 mics of fentanyl when you were putting the LMA in. There was never any discussion of like, “Do we actually need this?” It was the culture of what you did. That was how I was raised or how I trained at that time. One of the things that we had to do as part of our anesthesia program was to give a presentation to the anesthesia group.
For whatever reason, I had chosen or it was chosen for me to do multimodal analgesia. To fill the hour that I had to talk, I went down the pathway of some of these other techniques of esmolol, Lidocaine infusions, and Ketamine. I can’t remember if Precedex was in there or not because it had just come out. I was trying to figure it out earlier, and it had to have existed. I don’t know if I have had any exposure to it yet but the things like magnesium, Claritin, gabapentin, and some of these other medications. Through giving that presentation, I had this knowledge base of, 1) All the negative effects of opioids and, 2) All these options, even if I had never used them myself.
In my first job out of school, I had the freedom to start using the techniques and getting comfortable with them. At about that time, that group started getting heavily into starting an enhanced recovery after surgery program. They were looking for ways to cut back their opioid usage to do multimodal pain therapy. I had the green light to push the boundaries. In that practice again, it was very similar to where I trained.
They had a good regional anesthesia program. They were some of the early adopters of using TAP blocks and Pecs blocks because both of those techniques were brand new at that point. There was no QL, erector spinae or all these other blocks. Those were the first two fascial plane blocks that had come out. They were pretty early adopters of using those but then I was able to do things like start giving some ketamine on induction and start running a lidocaine infusion during a case.
When you start combining some of those techniques together intraoperatively, doing ketamine and lidocaine infusion and giving a little bit of Claritin upfront, the amount of fentanyl that I needed for my cases kept dropping every time I added another medication or technique. It got down to the point where I was giving between 25 to 50 mics of fentanyl on a case. I looked in the mirror one day and said, “Why am I still doing this?” This is a 2 to 3-hour case.
That 50 mics of fentanyl aren’t doing anything. By the time the patient is waking up, it’s metabolized and long gone. I wonder if I actually need it. Can we get to zero? It was this very scary thought because I had never given an anesthetic without fentanyl outside of maybe a hands surgery where I had put an LMA in without any fentanyl. I could logically lay out what’s the worst that happens. The patient gets a little tachycardiac, and we treat it.
Thirty seconds of a little elevation and heart rate isn’t going to cause any problems. The next day, I went to work with shaking hands. I drew up the fentanyl, labeled it, and set it on the anesthesia machine, so it would be there if I needed it. I went through the case, and everything was better. The hemodynamics were better. The patient breathed better at the end of the case. They woke up better and had less pain. It was like, “That was weird.”
I cut out pain medication, and the patient woke up with less pain, and it repeated itself. Every single case went like that. I then had to go looking in the literature for answers and see what was going on. That’s when I found out that opioid-free anesthesia is a thing. This was 2016 or 2017, somewhere in there. There were decades worth of research into it that I had never been exposed to. I had stumbled onto that. That was how I got started in it, which is backward from how most people do it. If you know me, it shouldn’t surprise you at all.
What is interesting to me is the fact that you were hesitant as well because you didn’t know any different. What I want to emphasize to the readers, especially if you are already a resident practicing is don’t be afraid to experiment with what you do. Obviously, all are in the realm of safety and optimizing patient outcomes. Don’t shy away from something that you’ve never done before because you’ve never done it.
Read the literature as Tom spoke to, understand what you are doing, how to maybe try different things and modalities, and then watch the outcomes, which is clearly what Tom did. He saw, “Based on this outcome, I actually proved myself correct. I proved that we don’t need fentanyl. Why am I giving it when there are other potential side effects that go along with it? There are other ways to manage pain.”
I love that story and the fact that you were curious. I also thought it’s interesting that you picked multimodal, whether you knew it or not back in school. It gave you the foundation to build SOFA. That’s cool. With Precedex, I remember using it in the ICU but in anesthesia, not so much in my training. In my practice, I got more comfortable using only the TAVRs.
We would routinely use Precedex and a little bit of fentanyl and versed for TAVRs but now I work at a peds hospital and you get little sticks of candy throughout your day, which I love. I even look at them as 1099, and they give you those little vials. I dilute it down to 4 mics and use that as an adjunct because it makes people wake up much smoother. They are not doing somersaults or pushups in bed when they wake up, which increases pain.
It’s interesting when you get comfortable with different medications. I would love to explore other things I myself have not actually used. We will get to the next question, which is, what exactly is opioid-free anesthesia in a literal sense? I know you mentioned ERAS, and we probably don’t have time to go into the entire protocol but you guys can look up ERAS which stands for Enhanced Recovery After Surgery. I love to give our students a concrete understanding of what drugs, and even regional you routinely use to deliver an opioid-free anesthetic.
Opioid-free anesthesia seems like it would be a pretty self-explanatory term. There’s actually a fair amount of debate in the literature about what exactly it is. Some of it seems semantics but the important thing is when you start looking at literature, doing research, and saying, “What is the best technique?” We look at this study, and they say these are the results. Is that truly comparable to another study talking about opioid-free anesthesia? In a sense, it matters and goes back a little bit to what our actual goals are. You might be tempted to look at the name opioid-free anesthesia and think that the goal is not to give opioids but that’s not the case.The goal of opioid-free anesthesia is not to completely cut out opioid medications. It's to have safer and better outcomes. Click To Tweet
We are not looking to demonize or completely cut out one class of medications. What we are looking to do is give a safe anesthetic, reduce the side effects, and have better outcomes. The way those two play into the discussion about what is opioid-free anesthesia is that there are some people who say, “This is an intraoperative technique. It’s opioid-free anesthesia.” Our goal is to provide an anesthetic with fewer side effects. Whereas there’s a group of people who also like to say, “It should be postoperative as well.” To a degree, that should be a goal but it’s a lot harder to get patients through the postoperative period when they are awake without any opioids than it is to do an opioid-free anesthetic.
Some of the detractors or critics of opioid-free anesthesia would like to say, “If the patient is going to get some Dilaudid, the surgeon is still going to write him a script for Percocet after the surgery is over.” You failed, and you’ve wasted your time doing this technique. If our goal were to eliminate opioids, that would be true but again, that’s not the case.
If we do an opioid-free anesthetic, we know that the patient is going to come into PACU with less respiratory depression, so they are going to be safer. There’s going to be a dramatic reduction in the risk of postoperative nausea and vomiting, which is the biggest cause of unexpected admissions after outpatient surgery. We are saving a lot of money and people from having to be admitted to the hospital unexpectedly.
There are a lot of positive effects to it, even if the patient still gets a little half a milligram of Dilaudid in PACU or even if they still take Percocet for a week after their surgery. The other discussion as far as what is opioid-free anesthesia is we could look at how we accomplish that. We could say that if I have a patient who’s going to do shoulder surgery, I do an inner scaling block. I put an LMA in, and the patient doesn’t get any fentanyl. They only have that block. You could call that an opioid-free anesthetic.
It’s the same way even if you’ve got a typical general surgery, a LAPCO or whatever the surgery is, I could take a small and titrate it to keep the heart rate and blood pressure under control, get the patient through the surgery with perfect vital signs and wake them up, and they haven’t had anything for analgesia. You could call that an opioid-free anesthetic.
What we are typically talking about is using some combination of non-opioid analgesics, and there’s a lot of focus on what are the secondary beneficial effects. We talk about ketamine being an anti-depressant and Precedex not only an analgesic but has an anti-anxiety and anti-shivering effect. All of these medications are also protective of surgical hyperalgesia, which is the changes that happen to our nervous system during surgery that make the pain so bad afterward.
If you look at those three scenarios, you could see how there are very different outcomes that you are going to get from doing an opioid-free anesthetic with a block versus controlling hemodynamics versus using these medications that are protective of the nervous system and non-opioid analgesics. That would probably be our classic definition. It is some combination of ketamine and Alpha-2 agonist, possibly a lidocaine infusion or magnesium. Sometimes we use some arsenal as an adjunct to those things.
We may use a block but typically, we are talking about TAP blocks or Pecs blocks that aren’t an anesthetic. You couldn’t give someone a Pecs block for a mastectomy and have them wide awake and able to go through the surgery, whereas you could do that with an interscalene block for shoulder surgery. That’s the classic definition but no one is come out or there isn’t agreement among all the people discussing opioid-free anesthesia.
Have you ever done a weight shoulder?
I have done a lightly sedated shoulder. I have done a block, given two Versed, and a very light Precedex infusion. We are familiar with this idea in OB that we can numb you up but you are still going to feel pressure. We don’t consider that with our peripheral nerve blocks because we always still put the patient to sleep or sedate them pretty severely. It’s something you have to consider.
Occasionally, you will get those patients with poor pulmonary function or whatever, where you don’t have the ability to give them a lot of anesthesia. You need a good block, and you need them to have that understanding. You are still going to know that they are up there doing something, and you are going to feel that tugging and pulling and all of that.
It’s a lot about expectations that we set as a provider to the patient from the beginning that can make or break your anesthetic and the pre-education piece of it. I’ve also equally experienced my patients saying, “They are scheduled for twilight anesthesia. I don’t want to remember a thing.” I’m like, “I can’t guarantee that with this type of anesthetic.” Yet they are terrified. They even hear anyone talking like, “You are not going to feel pain. I can assure you that.”
Maybe the local will numb you up but a lot of it is we play off what the patient wants for the experience versus probably even sometimes what’s the best anesthetic. I’ve had patients refuse spinals when it makes the most sense to have a spinal but you ultimately can’t give someone an anesthetic that they are refusing. I’m curious if you and I have never run a lidocaine infusion, what would you say is a common infusion rate that you typically find where you have your lidocaine infusions?
2 to 3 milligrams per kilo per hour. Typically, it all started out anywhere from 100 to 200 milligrams per hour. Somewhere in that ballpark.
Same with the mag. I’m curious because how would you dose your mag if you were using mag as an adjunct?
Magnesium, again, the textbook dose is 30 to 50 milligrams per kilo as a loading dose. You run that in over half an hour to an hour. Obviously, we are starting it right around induction, where there are going to be a lot of hemodynamic swings, and if you bullet it too quickly, it can contribute to the hypotension. How quickly that goes in is dependent on how the patient is responding to everything else that’s going on. That’s a 2 to 4-gram range, and honestly, my dose depends more on what facility I’m at and what supplies I have. It either comes in a 2-cc, 2-gram vial or it comes in a 4-gram, 100 ml piggyback. That plays a lot into it.
Same thing with ethanol. For people reading, do you equally have a syringe of ethanol that you bolus or do you do a straight infusion and titrate that?
If you are not doing all these other medications and looking for a way to decrease intraoperative opioid use or requirements, putting an esmolol infusion up and running it at a set rate is a great way to do that. The way that I use esmolol is in two situations. The first being cases where there’s no incision and no postoperative pain but I have to intubate the patient, so I want to control their heart rate and their blood pressure. Sometimes, that is in IR. The patient is going to get an ablation or we are going to do something with a threaded catheter somewhere. It could be doing an ERCP or an EGD where I need to intubate the patient to control their airway.If you're just looking for a way to decrease intraoperative opioid use, just set an esmolol infusion up and run it at a set rate. Click To Tweet
For any of those situations, I will bolus it on induction half to a milligram per kilo, so 50 to 100 milligrams as a bolus before I put the laryngoscope in their mouth or push the propofol. That will keep their heart rate in their blood pressure down. I can get them intubated, then I can turn the gas on and use that to keep their heart rate and blood pressure under control. That’s situation number 1). Situation number 2) Is short, fast outpatient surgeries. This could be a hysteroscopy or a general surgeon that does a 30-minute gallbladder. It’s a fast hernia repair. It’s cases where it’s still surgery, and there’s going to be some degree of postoperative pain but I need the patient to wake up very quickly.
What I will do is I will still give a small dose of ketamine, Precedex, and Lidocaine on induction. Maybe some magnesium but a much smaller dose than I would be giving someone who’s going to undergo a 2, 3 or 4-hour surgery where it’s got time to wear off a little bit. We are talking 10 to 20 milligrams of ketamine with 10 to 20 mics of Precedex. Small enough doses that I can give them to the patient and even after I’ve given them, they are not asleep.
They are still awake and talking to me, maybe slurring their speech a little bit but in half an hour, I can easily wake the patient up. Those doses are good for postoperative pain but they are not going to be totally sufficient for laryngoscopy for incision. I will use a small bolus of esmolol in addition to my smaller doses of ketamine and Precedex. That way, the patient is not sedated.
I hope you don’t mind me asking all these nitty-gritty practicals. I know that as a student learning, and I’m trying to understand this or probably thinking of, “How would I use this? What would I use it on, and how do I use it for this patient during this surgery?” This is great. I love all this advice. It goes to show that you are clearly very knowledgeable about what the expectation and the experience are of the patient in the surgery. That has allowed you to then tailor your opioid-free anesthetic to that surgery.
It’s not cookie-cutter, and you know as well as I do that because the expectation of one surgery from patient to patient is going to be different even then because everyone has their own tolerance and metabolism. If you get a redhead, you might have to do something different. This is great, and I hope you guys are all taking notes.
I know we already talked about some of the benefits of eliminating some postoperative side effects, and you equally said that it doesn’t mean that you are eliminating opioids from the postoperative period but it decreases the side effects in the postoperative period that allows patients to hopefully get out sooner. In the position I work at, we got an email because they were having issues with longer postoperative stays, and that’s money. The time they spend in PACU is very expensive.
It also sometimes gets into a situation where they can’t get the ORs emptied. I don’t know about you but I’ve had to wait in the OR before because they don’t even have a PACU bed. I have to take up OR time, which is even more expensive because the PACU is on hold. This also goes to show that as an anesthesia provider, you have to be cognizant of how you provide an anesthetic, which also plays into the cost of our medical system, the patient’s bill, and in general, the health of the hospital system as a whole. Obviously, the outcomes of the patient too. It all plays in a big triangle. What would you say to students who are in the position you were, and I have been, that maybe this is not routine practice?
It would be intimidating for a student to walk into an OR where they don’t routinely practice and say, “I’m going to do an esmolol infusion.” If you have the right preceptor, I highly encourage you to ask to say, “I would love to try this technique. Would you be willing to support me in my learning?” You would be surprised that a lot of people would be open to that. I know I sure would be. You definitely would have to know exactly what you want to do. You have to do your homework and know what you wanted to do. What recommendations would you give to students who maybe are looking for this experience but don’t necessarily have a clinical site that can provide that?
There are a couple of things that you have to get out of the way. First, as you said, you have to identify those preceptors who are interested and willing to stand up for you, facilitate that, and be willing to sign their name to that chart and try new things themselves. You have to go into this with the understanding that your first semester of clinical practice is probably not the time to start asking these questions.
Go in, learn to intubate, learn to do a more traditional anesthetic, get competent at that, and that builds trust. Get to the point where your preceptors don’t feel like they are constantly having to look over your shoulder and give you pointers through the whole case. When you get to the point where you can say to your preceptors, “This is where I’m at. I need you to be an extra set of hands if things start to go south or if you see me doing something or little finesse-type things that I could be doing better.”
That’s the time in your education to start saying, “What about this? I would like to try doing this.” Get solid on the basics first. The next thing you need to do is do a good job educating yourself on the doses, the side effects, the expectations, and how to do it. Go on all the podcasts, do as many interviews as you can get, have some studies on hand, print them up, bring them in with you, and maybe have that discussion a day before you want to do it.Before you try doing experimentation on anesthesia, learn the traditional way first. Get solid on the basics first. Click To Tweet
If you know who you are going to have tomorrow, give them a call that night or send them a text message and say, “We’ve got this tomorrow. I would like to try this technique.” It’s not like the patient rolls in the room, and you’ve got your stick academy, and then they are looking at you like, “What are you doing?” “We will do that here.” The other thing when you educate yourself on this stuff and do a good job of educating yourself on what are the real benefits like decreased respiratory depression and decreased postoperative nausea and vomiting.
Look for those opportunities and patient that has a strong history of throwing up after every surgery I’ve ever had. They put the patch behind my ear, they give me three drugs, and I still wake up throwing up or you will have that patient who’s in recovery from opioid addiction and saying, “I don’t want any opioids.” Look for those situations, and you will see this nod of people standing around going, “What do we do here? I don’t know what exactly.” You can say, “This is the issue. This is a possible solution. Why don’t we try that?” Look for those situations where it makes the most sense or there’s the most benefit.
That’s great advice to get that experience. We will end this with, no matter where you end up practicing and how the practice is, let’s talk about why it is important that everyone should understand how to utilize these medications during their anesthetic.
You are going to find people on both sides of this fence. Who says that opioid-free anesthesia is pointless or silly? Multimodal analgesia is one thing but we’ve gone too far and there are no benefits to it. We are creating more problems than we are solving. We’ve got people on the other side who are saying opioids are harmful. I’m never going to give an opioid intraoperatively again because there’s no reason for them.
They cause too many side effects, and then there are people at every point in the middle. As an anesthesia provider, you are going to run into all sorts of situations, and you need to know how to do anesthesia in as many ways as possible. You will find situations where opioids should be absolutely contraindicated in this patient.
For instance, the patient is refusing them. I keep going back to postoperative nausea and vomiting. That’s probably the most common indication that I see for opioid-free anesthesia. Patients with a strong history of postoperative nausea and vomiting. Historically, we have brushed that off as the cost of doing business. If you get an anesthetic, you are at risk for this.
When you talk about being able to dramatically reduce the number of patients who have it and reduce the number of patients who are getting admitted to the hospital after surgery, that’s a huge cost savings. You are talking about tens of thousands of dollars a day for an avoidable side effect. Things like respiratory depression and all sorts of things, there’s a large number of indications for opioid-free anesthesia. You should be able to do it both ways, and that should be a tool you have in your tool chest.
I loved when you said you should be able to provide anesthesia in as many ways as possible. This comes over time and with experience but the more you get comfortable with your career, the more you experiment and understand how you can use things to achieve better outcomes for your patient. The more satisfying, the more rewarding.
The better outcomes you are going to get, the more rewarding your career is going to be. I’m probably someone who could say I’m in the middle where I value this technique and implement it in my practice from time to time but not always. It’s one of those things I equally have seen the negative side effects of opioids, running high infusions, and hyperalgesia.
You never strive to have a patient wake up in pain. Sometimes, you think you are doing good by providing an opioid anesthetic but in reality, you could be causing the hyperalgesia from it. Thinking about that ahead of time allows you to come up with a better plan. It’s about tailoring it to what the patient needs and the type of surgery. This is all great advice. Thank you so much for sharing. I would love to touch on lastly how you have a pain fellowship from the University of South Florida. Is that correct?
I don’t think a lot of people are knowledgeable enough to know about that opportunity for CRNAs. How did that experience go, and how do people look into that after they graduate from CRNA school to get a fellowship?
There are two universities that offer fellowships in chronic pain management. What we are talking about is stepping out of the operating room. You are no longer giving anesthesia. You are on the procedure list. Patients are coming to you with chronic pain conditions. You see them, evaluate them, diagnose them, order testing, and then you are doing things like epidural steroid injections, trigger point injections, nerve ablations, and all that thing that goes into treating patients with chronic pain.
This is a huge opportunity for CRNAs because we are already familiar with pain in general; instead of being focused on acute pain, it’s much more of a deep dive into the disease process and how our nervous system changes, gets damaged, and how we can fix that. Chronic pain is an absolute epidemic in this country. There are more people being treated for chronic pain than there are all types of cancer put together.Chronic pain is an absolute epidemic in the US. There are more people being treated for chronic pain than there are for cancer. Click To Tweet
There is a huge lack of people who are able to do it. Whatever your credentials are, if you are a physician or CRNA, there are not enough people out there doing this. Depending on your state and the rules, you may or may not be involved in the medical management of it and prescribing things like gabapentin, muscle relaxants, and opioids for patients who have been on them for a long time. There are states where we are not allowed to do that. A lot of times, your family doctor or someone will manage the medical side, and you will come in. Sometimes, they will need an ablation every six months to a year. That’s what the job is.
The fellowship itself is a year long. A lot of the didactic portion of it is online and able to be done long distance. It’s very challenging and different than what you learn in anesthesia school. It’s almost a profession. You then go through a hands-on clinical portion where you go to an established pain practice and do hundreds of injections so that you are competent and able to do that on your own once you get out.
Thank you for sharing all the information. For those of you reading, I 100% agree with Tom that this is mind-blowing that more people suffer from chronic pain than cancer. It’s sad and unfortunate but it goes to show that clearly, we do not have enough skilled providers to be able to provide this service. Keep it in mind. If that’s something that you are interested in, there are only two places. Hopefully, over the next coming years, we will see more popping up.
It’s growing very quickly.
Thank you, Tom, for your time. I appreciate you so very much. Where can people connect with you and find you both on social?
All of my social media is at @BaribeaultOFA. If you are interested in opioid-free anesthesia, the society’s website is GoOpioidFree.com. We do have a resident rate. If you are in school, it’s much more affordable for you. We have a conference coming up from March 31st to April 2nd, 2023. We are looking for nurse anesthesia residents who have done their Doctoral project on opioid-free anesthesia and would like to do a poster presentation at our meeting.
That’s something that we are going to be doing at our future meetings as well. If you are at the point in your program where you are deciding on what your project should be, keep that in mind. We do partner with a lot of residents doing their Doctoral projects, and we will help you out with things like reference lists and refine your project. We will host your work on the member’s part of our website after you are all done. We spend a lot of time working with residents and trying to educate them about opioid-free anesthesia.
This is a great opportunity. For those of you who are early on your journey, make sure you put it on your dream board to keep Tom in mind. That’s a great opportunity to not only hone in on this skill but to connect with the community and network. It could mean a pretty dramatic difference in your future in your career as an anesthesia provider. I highly encourage that. Thank you so very much, Tom. It has been a pleasure, and I look forward to having you back on the show in the future. We will be in touch.
Thanks. I had a great time.
- Society for Opioid-free Anesthesia
- @BaribeaultOFA – Instagram
About Thomas Baribeault
Thomas Baribeault is a clinical coordinator and chief obstetric CRNA for Commonwealth Anesthesia in Lexington KY. He specializes in obstetric anesthesia, acute surgical pain management, non-surgical pain management, and point-of-care ultrasound. He founded the Society for Opioid-Free Anesthesia (SOFA) which is a non-profit organization dedicated to education and research on opioid-free anesthesia and post-operative pain management.
He received a bachelor’s degree in nursing from the Ohio State University, a master’s of science in nursing and anesthesia residency from Case Western Reserve University and a doctorate in nursing practice and pain management fellowship from the University of South Florida.