Background
The United States is in the midst of an unprecedented opioid epidemic [1]. While opioids are widely used in the perioperative setting, little is understood about how perioperative practices influence chronic opioid use. Recent developments in care redesign processes have promoted the application of concepts such as Enhanced Recovery After Surgery (ERAS) to improve quality of care and patient outcomes. Opioid-free analgesia (OFA) and opioid-sparing techniques are key elements of ERAS protocols.
We recently launched an ERAS program for colorectal surgery, and we report the impact of this implementation on perioperative opioid utilization, postsurgical pain scores, and the incidence of opioid prescription at hospital discharge.
Methods
We conducted a retrospective analysis of adult patients undergoing elective colorectal surgery from January to December 2016. Patients in the intervention group were treated according our ERAS guidelines. These guidelines incorporate glucose management, goal-directed fluid therapy, postoperative nausea and vomiting prevention, lung-protective ventilation, and OFA and opioid-sparing techniques (regional anesthesia, ketamine infusion, intravenous acetaminophen, and oral celecoxib). We compared patients undergoing surgery with the ERAS intervention to a historical control group of propensity-matched patients who underwent similar surgeries prior to the ERAS intervention.
The primary outcome measure was a dichotomous indicator noting the presence of an opioid prescription on discharge. Secondary outcome measures were pain score on day of discharge (4, mild-to-moderate and > 4, moderate-to-severe), OFA (defined as no opioid administered intraoperatively), and utilization of regional anesthesia.
Results
One hundred and four patients were treated in the ERAS group, and 69 of these patients were matched to a historical control group of 69 non-ERAS patients. ERAS patients were more likely to receive OFA (70% vs 29%, p<0.001) and regional anesthesia (96% vs. 86%, p=0.041) compared to the control group. Moderate-to-severe pain scores were not significantly different in the ERAS and control groups (32% vs 37%, p=0.617), and 94% of patients in both groups were discharged with an opioid prescription.
In both groups, all patients with moderate-to-severe pain (44/44) were discharged with an opioid prescription compared to 90.4% (75/83) of patients with mild-to-moderate pain (p=0.050).
Conclusions
Our retrospective analysis of patients undergoing elective colorectal surgery found that utilization of OFA and regional anesthesia increased significantly after ERAS implementation and was not associated with increased discharge pain scores. However, this did not reduce the incidence of opioid prescription at hospital discharge; nearly 9 in 10 patients with discharge pain scores 4 in both groups were discharged with an opioid.
Our finding that 90% of patients with mild-to-moderate pain following elective colorectal surgery were discharged with an opioid prescription indicates that physician behavior, rather than patient condition, may be the primary determinant of opioid prescribing practices in our study. In addition to redesigning perioperative care processes, efforts should be made to modify physician perioperative behavior with the ultimate goal of curtailing the use of opioids at the population level.
References
- “The Opioid Epidemic: By the Numbers”. https://www.hhs.gov/sites/default/files/Factsheet-opioids-061516.pdf. January 2017.
