I have had surgery only once and my only request was to not give me any narcotic unless I was awake after the surgery and asked for them if I felt my pain was otherwise intolerable. When the nurses came around postop to offer prn narcotics post op, I sent them to get me a new ice pack. I did not take a single narcotic dose post op. I realize pain tolerance varies from patient to patient and if patients wake up in pain, I treat it but I cringe at how many blast patients with 2mg Dilaudid prior to emergence routinely.If I do a block plus TIVA or GA, then no opioids during surgery. Without a block, I may add opioid at the end of the procedure before extubation but only after they are breathing with a decent rate and TV on their own off ventilator. Opioids are probably drastically overused during surgery and can lead to increased usage post op and potentially chemical dependency. It is astonishing how a patient with complete anesthesia from a brachial plexus block ends up receiving 250mcg fentanyl while on a phenylephrine drip for a sitting shoulder procedure, only to enter PACU nauseated but still completely anesthetic over the entire shoulder and neck.
I started cardiac anesthesia in the era when the dogma was that inhalation agents were avoided and 70-80ug fentanyl/kg or 10-20 ug/kg sufenta were given with valium and later midazolam with pancuronium was the anesthetic. My thinking on narcotics intraop has changed drastically over my career.