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Nonopioid Directives: Unintended Consequences in the Operating Room.

The persistent rise in drug overdose deaths has led state and federal government policy makers to consider novel approaches that limit opioid exposure to prevent downstream harms. For example, many states initially targeted prescriber behaviors by limiting the dose or duration of opioid prescriptions.1 More recently, some of these states have pursued policies that mandate the use of opioid alternatives based on patient preferences—the nonopioid directive. The idea is straightforward: patients sign a directive stating that under no circumstance should they be administered an opioid medication. Such a directive empowers the patient to refuse all opioid medication across all phases of care, and this expression of patient autonomy aligns with a key tenet of medical ethics.2 However, unlike other advance directives, which primarily focus on patient preferences for end-of-life care, the mandate from a nonopioid directive may lead to unintended consequences, specifically in the context of perioperative care. As state and federal legislatures debate the topic, it is important to recognize that the intraoperative period is a unique clinical setting that deserves an exemption from nonopioid directives to uphold patient safety.