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Opioid-free surgery treats pain at every physical and emotional level

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theconversation.com – Heather Margonari, Lead Coordinator for the Opioid Free Pathway, University of Pittsburgh – 2024-11-25 07:42:00

Opioids have been an essential part of anesthesia, but they aren’t the only way to manage pain.

Hispanolistic/E+ via Getty Images

Heather Margonari, University of Pittsburgh; Jacques E. Chelly, University of Pittsburgh, and Shiv K. Goel, University of Pittsburgh

The opioid crisis remains a significant public health challenge in the United States. In 2022, over 2.5 million American adults had an opioid use disorder, and opioids accounted for nearly 76% of overdose deaths.

Some patients are fearful of using opioids after surgery due to concerns about dependence and potential side effects, even when appropriately prescribed by a doctor to manage pain. Surgery is often the first time patients receive an opioid prescription, and their widespread use raises concerns about patients becoming long-term users. Leftover pills from a patient’s prescriptions may also be misused.

Researchers like us are working to develop a personalized and comprehensive surgical experience that doesn’t use opioids. Our approach to opioid-free surgery addresses both physical and emotional well-being through effective anesthesia and complementary pain-management techniques.

What is opioid-free anesthesia?

Clinicians have used morphine and other opioids to manage pain for thousands of years. These drugs remain integral to anesthesia.

Most surgical procedures use a strategy called balanced anesthesia, which combines drugs that induce sleep and relax muscles with opioids to control pain. However, using opioids in anesthesia can lead to unwanted side effects, such as serious cardiac and respiratory problems, nausea and vomiting, and digestive issues.

Concerns over these adverse effects and the opioid crisis have fueled the development of opioid-free anesthesia. This approach uses non-opioid drugs to relieve pain before, during and after surgery while minimizing the risk of side effects and dependency. Studies have shown that opioid-free anesthesia can provide similar levels of pain relief to traditional methods using opioids.

Opioid-free anesthesia is currently based on a multimodal approach. This means treatments are designed to target various pain receptors beyond opioid receptors in the spinal cord. Multimodal analgesia uses a combination of at least two medications or anesthetic techniques, each relieving pain through distinct mechanisms. The aim is to effectively block or modulate pain signals from the brain, spinal cord and the nerves of the body.

Close-up of IV bag with other medical equipment in the background out of focus

Balanced anesthesia combines a number of different drugs to ensure a smooth surgery.

bymuratdeniz/E+ via Getty Images

For instance, nonsteroidal anti-inflammatory drugs, or NSAIDs, such as ibuprofen work by inhibiting COX enzymes that promote inflammation. Acetaminophen, or Tylenol, similarly inhibits COX enzymes. While both acetaminophen and NSAIDs primarily target pain at the surgical site, they can also exert effects at the spinal level after several days of use.

A class of drugs called gabapentinoids, which include gabapentin and pregabalin, target certain proteins to dampen nerve signal transmission. This decreases neuropathic pain by reducing nerve inflammation.

The anesthetic ketamine disrupts pain pathways that contribute to a condition called central sensitization. This disorder occurs when nerve cells in the spinal cord and brain amplify pain signals even when the original injury or source of pain has healed. As a result, normal sensations such as light touch or mild pressure may be perceived as painful, and painful stimuli may feel more intense than usual. By lessening pain sensitivity, ketamine can help reduce the risk of chronic pain.

Regional anesthesia involves injecting local anesthetics near nerves to block pain signals to the brain. This method allows patients to remain awake but pain-free in the numbed area, reducing the need for general anesthesia and its side effects. Common regional techniques include epidurals, spinal anesthesia and nerve blocks.

By activating different pain pathways simultaneously, multimodal approaches aim to enhance pain relief synergistically.

Psychology of pain perception

Psychological factors can significantly influence a patient’s perception of pain. Research indicates that mental health conditions such as anxiety, depression and sleep disturbances can increase pain levels by up to 50%. This suggests that addressing mood and sleep issues can be essential for pain management and improving overall patient well-being.

Psychological states can intensify the perception of pain by significantly influencing the neural pathways related to pain processing. For example, anxiety and stress activate the body’s fight or flight response, prompting the release of stress hormones that heighten nerve sensitivity. This can make pain feel more intense. Research has also found that higher anxiety levels before surgery are linked to increased anesthesia use during surgery and opioid consumption after surgery.

Patient lying on operating table under blanket, smiling up at provider

Addressing pain before an operation can make patients feel better post-op.

ljubaphoto/E+ via Getty Images

Complementary and alternative techniques that address psychological factors can reduce pain and opioid use by modulating pain transmission in the nervous system and activating neurochemical pathways that promote pain relief.

For example, aromatherapy uses essential oils to stimulate the olfactory system. This can help reduce pain perception and enhance overall well-being by evoking emotional responses and promoting relaxation.

Music therapy stimulates the auditory system, which can distract patients from pain, lower anxiety levels and foster emotional healing. This can ultimately lead to reduced pain perception.

Relaxation exercises, such as deep breathing and progressive muscle relaxation, activate the parasympathetic nervous system and help promote a state of rest. Engaging the parasympathetic system helps the body conserve energy, slow your heart rate, lower blood pressure and relieve muscle tension. This can lead to decreased pain sensitivity by promoting a state of calmness.

Acupuncture involves inserting thin needles into specific body points, stimulating the release of endorphins and other neurotransmitters. These molecules can interrupt pain signals and promote healing processes within the body.

Moving toward opioid-free surgery

Transitioning away from opioids in surgery requires a shift in both practice and mindset across the entire health care team. Beyond anesthesiologists, other providers, including surgeons, nurses and medical trainees, also use opioids in patient care. All providers would need to be open to using alternative pain management techniques throughout the surgical process.

In response to the increasing patient demand for opioid-free surgical care, our team at the University of Pittsburgh Medical Center launched the patient-initiated Opioid-Free Surgical Pain Management Program in May 2024. To address both the physical and emotional dimensions of pain while optimizing recovery and safety, we recruited surgeons, anesthesiologists, nurses, pharmacists and hospital administrators to participate in the initiative.

Over the course of six months, our team enrolled 109 patients, 79 of whom successfully underwent surgeries without opioids. Barriers to participating in the program included patient perception of severe pain, inadequately addressing stress and anxiety before the operation and limited education in the department about the program.

However, subsequent refinements to the program – such as giving patients muscle relaxants while they were recovering from anesthesia – improved participation and reduced opioid use. Importantly, none of the 19 patients who received opioids while recovering in the hospital post-op required further opioid prescriptions at discharge.

These results reflect the promise of our pathway to minimize reliance on opioids while ensuring effective pain management. Enhanced psychological support for patients and education for providers in surgery departments can broaden the effectiveness of a comprehensive approach to managing pain.The Conversation

Heather Margonari, Lead Coordinator for the Opioid Free Pathway, University of Pittsburgh; Jacques E. Chelly, Professor of Anesthesiology, Perioperative Medicine and Orthopedic Surgery, University of Pittsburgh, and Shiv K. Goel, Clinical Associate Professor of Anesthesiology, University of Pittsburgh

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Out-of-balance bacteria is linked to multiple sclerosis − the ratio can predict severity of disease

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theconversation.com – Ashutosh Mangalam, Associate Professor of Pathology, University of Iowa – 2025-03-03 14:03:00

Out-of-balance bacteria is linked to multiple sclerosis − the ratio can predict severity of disease

The myelin sheaths insulating neurons are damaged in multiple sclerosis.
Steve Gschmeissner/Science Photo Library/Brand X Pictures via Getty Images

Ashutosh Mangalam, University of Iowa

Multiple sclerosis is a disease that results when the immune system mistakenly attacks the brain and spinal cord. It affects nearly one million people in the U.S. and over 2.8 million worldwide. While genetics play a role in the risk of developing multiple sclerosis, environmental factors such as diet, infectious disease and gut health are major contributors.

The environment plays a key role in determining who develops multiple sclerosis, and this is evident from twin studies. Among identical twins who share 100% of their genes, one twin has a roughly 25% chance of developing MS if the other twin has the disease. For fraternal twins who share 50% of their genes, this rate drops to around 2%.

Scientists have long suspected that gut bacteria may influence a person’s risk of developing multiple sclerosis. But studies so far have had inconsistent findings.

To address these inconsistencies, my colleagues and I used what researchers call a bedside-to-bench-to-bedside approach: starting with samples from patients with multiple sclerosis, conducting lab experiments on these samples, then confirming our findings in patients.

In our newly published research, we found that the ratio of two bacteria in the gut can predict multiple sclerosis severity in patients, highlighting the importance of the microbiome and gut health in this disease.

Microscopy image of large clump of rod-like bacteria
Akkermansia is commonly found in the human gut microbiome.
Zhang et al/Microbial Biotechnology, CC BY-SA

Bedside to bench

First, we analyzed the chemical and bacterial gut composition of patients with multiple sclerosis, confirming that they had gut inflammation and different types of gut bacteria compared with people without multiple sclerosis.

Specifically, we showed that a group of bacteria called Blautia was more common in multiple sclerosis patients, while Prevotella, a bacterial species consistently linked to a healthy gut, was found in lower amounts.

In a separate experiment in mice, we observed that the balance between two gut bacteria, Bifidobacterium and Akkermansia, was critical in distinguishing mice with or without multiple sclerosis-like disease. Mice with multiple sclerosis-like symptoms had increased levels of Akkermansia and decreased levels of Bifidobacterium in their stool or gut lining.

Bench to bedside

To explore this further, we treated mice with antibiotics to remove all their gut bacteria. Then, we gave either Blautia, which was higher in multiple sclerosis patients; Prevotella, which was more common in healthy patients; or a control bacteria, Phocaeicola, which is found in patients with and without multiple sclerosis. We found that mice with Blautia developed more gut inflammation and worse multiple sclerosis-like symptoms.

Even before symptoms appeared, these mice had low levels of Bifidobacterium and high levels of Akkermansia. This suggested that an imbalance between these two bacteria might not just be a sign of disease, but could actually predict how severe it will be.

We then examined whether this same imbalance appeared in people. We measured the ratio of Bifidobacterium adolescentis and Akkermansia muciniphila in samples from multiple sclerosis patients in Iowa and participants in a study spanning the U.S., Latin America and Europe.

Our findings were consistent: Patients with multiple sclerosis had a lower ratio of Bifidobacterium to Akkermansia. This imbalance was not only linked to having multiple sclerosis but also with worse disability, making it a stronger predictor of disease severity than any single type of bacteria alone.

Microscopy image of clusters of rod bacteria
Bifidobacterium both produces and consumes mucin, a glycoprotein that protects the gut lining.
Paola Mattarelli and Monica Modesto/Katz Lab via Flickr, CC BY-NC

How ‘good’ bacteria can become harmful

One of the most interesting findings from our study was that normally beneficial bacteria can turn harmful in multiple sclerosis. Akkermansia is usually considered a helpful bacterium, but it became problematic in patients with multiple sclerosis.

A previous study in mice showed a similar pattern: Mice with severe disease had a lower Bifidobacterium-to-Akkermansia ratio. In that study, mice fed a diet rich in phytoestrogens – chemicals structurally similar to human estrogen that need to be broken down by bacteria for beneficial health effects – developed milder disease than those on a diet without phytoestrogens. Previously we have shown that people with multiple sclerosis lack gut bacteria that can metabolize phytoestrogen.

Although the precise mechanisms behind the link between the Bifidobacterium-to- Akkermansia ratio and multiple sclerosis is unknown, researchers have a theory. Both types of bacteria consume mucin, a substance that protects the gut lining. However, Bifidobacterium both eats and produces mucin, while Akkermansia only consumes it. When Bifidobacterium levels drop, such as during inflammation, Akkermansia overconsumes mucin and weakens the gut lining. This process can trigger more inflammation and potentially contribute to the progression of multiple sclerosis.

Our finding that the Bifidobacterium-to-Akkermansia ratio may be a key marker for multiple sclerosis severity could help improve diagnosis and treatment. It also highlights how losing beneficial gut bacteria can allow other gut bacteria to become harmful, though it is unclear whether changing levels of certain microbes can affect multiple sclerosis.

While more research can help clarify the link between the gut microbiome and multiple sclerosis, these findings offer a promising new direction for understanding and treating this disease.The Conversation

Ashutosh Mangalam, Associate Professor of Pathology, University of Iowa

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How are clouds’ shapes made? A scientist explains the different cloud types and how they help forecast weather

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theconversation.com – Ross Lazear, Instructor in Atmospheric and Environmental Sciences, University at Albany, State University of New York – 2025-03-03 07:18:00

Lenticular clouds, like this one over a mountain in Chile, can look like flying saucers.
Bilderbuch/Design Pics Editorial/Universal Images Group via Getty Images

Ross Lazear, University at Albany, State University of New York

Curious Kids is a series for children of all ages. If you have a question you’d like an expert to answer, send it to curiouskidsus@theconversation.com.


How are clouds’ shapes made? – Amanda, age 5, Chile


I’m a meteorologist, and I’ve been fascinated by weather since I was 8 years old. I grew up in Minnesota, where the weather changes from wind-whipping blizzards in winter to severe thunderstorms – sometimes with tornadoes – in the summer. So, it’s not all that surprising that I’ve spent most of my life looking at clouds.

All clouds form as a result of saturation – that’s when the air contains so much water vapor that it begins producing liquid or ice.

Once you understand how certain clouds develop their shapes, you can learn to forecast the weather.

A view showing typical cloud heights shows tall cumulonimbus clouds, low level cumulus and high-level cirrus.
Cloud types show their general heights.
Australian Bureau of Meteorology

Cotton ball cumulus clouds

Clouds that look like cartoon cotton balls or cauliflower are made up of tiny liquid water droplets and are called cumulus clouds.

Often, these are fair-weather clouds that form when the Sun warms the ground and the warm air rises. You’ll often see them on humid summer days.

A horse or donkey next to river bank with puffy clouds in the sky.
Cumulus clouds over Lander, Wyo.
Ross Lazear, CC BY-ND

However, if the air is particularly warm and humid, and the atmosphere above is much colder, cumulus clouds can rapidly grow vertically into cumulonimbus. When the edges of these clouds look especially crisp, it’s a sign that heavy rain or snow may be imminent.

Wispy cirrus are ice clouds

When cumulonimbus clouds grow high enough into the atmosphere, the temperature becomes cold enough for ice clouds, or cirrus, to form.

Clouds made up entirely of ice are usually more transparent. In some cases, you can see the Sun or Moon through them.

Streaks of high white clouds look like paintbrush strokes
Cirrus clouds over the roof of Bard College in Annandale-on-Hudson, N.Y.
Ross Lazear, CC BY-ND

Cirrus clouds that forms atop a thunderstorm spread outward and can form anvil clouds. These clouds flatten on top as they reach the stratosphere, where the atmosphere begins to warm with height.

However, most cirrus clouds aren’t associated with storms at all. There are many ice clouds associated with tranquil weather that are simply regions of the atmosphere with more moisture but not precipitation.

Fog and stratus clouds

Clouds are a result of saturation, but saturated air can also exist at ground level. When this occurs, we call it fog.

In temperatures below freezing, fog can actually deposit ice onto objects at or near the ground, called rime ice.

YouTube video
Reading clouds, with the National Oceanic and Atmospheric Administration.

When clouds form thick layers, we add the word “stratus,” or “layer,” to the name. Stratus can occur just above the ground, or a bit higher up – we call it altostratus then. It can occur even higher and become cirrostratus, or a layer or ice clouds.

If there’s enough moisture and lift, stratus clouds can create rain or snow. These are nimbostratus.

How mountains can create their own clouds

There are a number of other unique and beautiful cloud types that can form as air rises over mountain slopes and other topography.

Lenticular clouds, for example, can look like flying saucers hovering just above, or near, mountaintops. Lenticular clouds can actually form far from mountains, as wind over a mountain range creates an effect like ripples in a pond.

A cloud appears to stream off the side of a tall mountain peak.
A banner cloud appears to stream out from the Matterhorn, in the Alps on the border between Italy and Switzerland.
Zacharie Grossen via Wikimedia, CC BY

Rarer are banner clouds, which form from horizontally spinning air on one side of a mountain.

Wind plays a big role

You might have looked up at the sky and noticed one layer of clouds moving in a different direction from another. Clouds move along with the wind, so what you’re seeing is the wind changing direction with height.

Cirrus clouds at the level of the jet stream – often about 6 miles (10 kilometers), above the ground – can sometimes move at over 200 miles per hour (320 kilometers per hour). But because they are so high up, it’s often hard to tell how fast they are moving.


Hello, curious kids! Do you have a question you’d like an expert to answer? Ask an adult to send your question to CuriousKidsUS@theconversation.com. Please tell us your name, age and the city where you live.

And since curiosity has no age limit – adults, let us know what you’re wondering, too. We won’t be able to answer every question, but we will do our best.The Conversation

Ross Lazear, Instructor in Atmospheric and Environmental Sciences, University at Albany, State University of New York

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Who’s who at the Vatican?

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theconversation.com – Daniel Speed Thompson, Associate Professor of Religious Studies, University of Dayton – 2025-03-03 07:18:00

Who’s who at the Vatican?

Deacons take part in a mass in St. Peter’s Basilica that was supposed to be presided over by Pope Francis.
AP Photo/Alessandra Tarantino

Daniel Speed Thompson, University of Dayton

For more than two weeks, eyes have been on the Vatican, awaiting news about Pope Francis’ health. The pope has been at Rome’s Gemelli Hospital since Feb. 14, 2025, being treated for double pneumonia and other complications.

When a pope is ill, resigns or passes away, who steps in? And who else helps lead the Holy See? The Conversation U.S. asked Daniel Speed Thompson, a theologian at the University of Dayton, for some insight into Vatican City.

Who are the most powerful people at the Vatican, besides the pope?

The Vatican houses the central government of the Catholic Church and is also an independent city-state. The pope is both the head of the Catholic Church and head of state.

In order to govern both, he has the Roman Curia, meaning “court.” In modern terms, the Curia is the papal bureaucracy. It is an extension of the pope’s authority.

In Catholic doctrine, the pope has the highest authority in the church. He can exercise it alone or with the College of Bishops, made up of all the bishops in the world. Bishops named by the pope to the office of “cardinal” can, if under 80 years old, vote to elect a new pope. Some cardinals, but by no means all, serve in the papal Curia in Rome.

Besides the pope, curial officials who oversee important aspects of the church’s political and religious life are often powerful figures. For example, the secretariat of state, headed by Cardinal Pietro Parolin, oversees relations with other countries and international organizations. It also oversees the Vatican’s diplomatic corps.

Two men in black robes with red skullcaps and red sashes walk on a paved road, flanking a man in white robes.
Pope Francis smiles as he walks alongside Vatican Secretary of State Pietro Parolin, left, and Cardinal Giuseppe Versaldi at the Vatican in 2014.
AP Photo/Gregorio Borgia

The Dicastery – “department” – for the Doctrine of the Faith, led by Cardinal Víctor Manuel Fernández, addresses questions about correct Catholic teaching on faith and morals. The Dicastery of Bishops, headed by Cardinal Robert Prevost, coordinates the nominations of new bishops around the world.

All these officials work under the authority of the pope, advocating for and implementing his agenda. For example, Prevost has suggested that all Catholics should be involved in the selection of bishops. This idea is linked with Francis’ call for a more “synodal” church: one that is less hierarchical and shaped by lay Catholics’ concerns and challenges.

If a pope can’t fulfill his duties, who steps in?

When a pope dies – or resigns, like Benedict XVI did in 2013 – the governance of the Catholic Church formally falls to the College of Cardinals. However, the authority of the college is very limited. On their own, cardinals cannot make any significant decisions concerning faith, morals and worship. Nor can they undo previous papal decisions or change church laws about electing a new pope.

All the heads of the dicasteries lose their office upon the death or resignation of a pope. The College of Cardinals serves as a caretaker government whose primary purpose is to prepare for the election of the new pope and oversee day-to-day workings of the Vatican.

One cardinal, known as the “camerlengo,” is responsible for confirming the pope’s death or resignation. He then assumes control over the pope’s residence and coordinates the funeral, if needed. The camerlengo also takes custody of the Vatican’s property in Rome and supervises details for the upcoming conclave.

A man wearing a priest's collar gestures as he speaks, sitting in front of a framed portrait of Pope Francis.
Cardinal Camerlengo Kevin Farrell talks with The Associated Press in his office in Rome in 2018.
AP Photo/Paolo Santalucia

The day-to-day business of the Catholic Church continues, but no big decisions can be made in the absence of a pope. The church cannot appoint new bishops, and the Vatican cannot start new diplomatic efforts.

Are officials at the Vatican often nominated to be pope?

Sometimes. Francis was a cardinal from Argentina before his election as pope and had not served in the Roman Curia. However, Benedict XVI, Francis’ predecessor, did serve as the prefect of the Congregation – now called Dicastery – for the Doctrine of the Faith. Some recent popes served in the Curia earlier in their career but not immediately before their election.

What do you wish more people understood about the Vatican?

Three things. First, the Vatican is unlike any organization in the world. Its religious mission and political status rest on nearly 2,000 years of history. This complicated story provides a unique tradition that anchors the institution of the Catholic Church, but can also block the church from critical self-examination and renewal.

Second, the Vatican is like every organization in the world. Vatican officials can be faithful to the highest standards of their religion, truly wishing to serve the church and the common good of humanity. But they can also be flagrantly immoral, even criminals, and careerist seekers of status or luxury. Francis has consistently called out priests and bishops who see themselves as somehow superior by virtue of their office or their ordination.

Finally, compared with the massive bureaucracies of modern governments and corporations, the Vatican is relatively small and not as wealthy as it is often portrayed.

Although the Curia manages a vast international organization, its resources are far closer to my own midsize Catholic university than to the U.S. government or Apple. Vatican City and the Holy See employ about 2,000 people, with an operating budget of about US$835 million.

Yes, the Catholic Church has wealth – and the ongoing problem of deficits and financial corruption. But the Vatican’s resources pale in comparison with what a modern state or large company can muster.The Conversation

Daniel Speed Thompson, Associate Professor of Religious Studies, University of Dayton

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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