Impact of Enhanced Recovery After Surgery and Opioid-Free Anesthesia on Opioid Prescriptions at Discharge From the Hospital: A Historical-Prospective Study

Abstract

Background: The United States is in the midst of an opioid epidemic, and opioid use disorder often begins with a prescription for acute pain. The perioperative period represents an important opportunity to prevent chronic opioid use, and recently there has been a paradigm shift toward implementation of enhanced recovery after surgery (ERAS) protocols that promote opioid-free and multimodal analgesia. The objective of this study was to assess the impact of an ERAS intervention for colorectal surgery on discharge opioid prescribing practices.

Methods: We conducted a historical-prospective quality improvement study of an ERAS protocol implemented for patients undergoing colorectal surgery with a focus on the opioid-free and multimodal analgesia components of the pathway. We compared patients undergoing colorectal surgery 1 year before implementation (June 15, 2015, to June 14, 2016) and 1 year after implementation (June 15, 2016, to June 14, 2017).

Results: Before the ERAS intervention, opioids at discharge were not significantly increasing (1% per month; 95% confidence interval [CI], -1% to 3%; P = .199). Immediately after the ERAS intervention, opioid prescriptions were not significantly lower (13%; 95% CI, -30% to 3%; P = .110). After the intervention, the rate of opioid prescriptions at discharge did not decrease significantly 1% (95% CI, -3% to 1%) compared to the pre-period rate (P = .399). Subgroup analysis showed that in patients with a combination of low discharge pain scores, no preoperative opioid use, and low morphine milligram equivalents consumption before discharge, the rate of discharge opioid prescription was 72% (95% CI, 61%-83%).

Conclusions: This study is the first to report discharge opioid prescribing practices in an ERAS setting. Although an ERAS intervention for colorectal surgery led to an increase in opioid-free anesthesia and multimodal analgesia, we did not observe an impact on discharge opioid prescribing practices. The majority of patients were discharged with an opioid prescription, including those with a combination of low discharge pain scores, no preoperative opioid use, and low morphine milligram equivalents consumption before discharge. This observation in the setting of an ERAS pathway that promotes multimodal analgesia suggests that our findings are very likely to also be observed in non-ERAS settings and offers an opportunity to modify opioid prescribing practices on discharge after surgery. For opioid-free anesthesia and multimodal analgesia to influence the opioid epidemic, the dose and quantity of the opioids prescribed should be modified based on the information gathered by in-hospital pain scores and opioid use as well as pain history before admission.

Figure 1.

UCLA enhanced recovery after surgery anesthesia protocol. ABG indicates arterial blood gas; BG, blood glucose; BS, blood sugar; d/c, discontinue; Fio₂, fraction of inspired oxygen; FSBG, fingerstick blood glucose; gtt, glucose tolerance test; HR, heart rate; IBD, inflamma- t bowel disease; ISS, Injury Severity Score; IV, intravenous; MIVF, maintenance intravenous fluids; OR, operating room; PACU, postanesthesia recovery unit; PEEP positive end-expiratory pressure; PO, oral; PONV, postoperative nausea and vomiting; PTU, procedural treatment unit; PVI, pleth variability index; Q1H, every hour; Q6H, every 6 hours; SV, stroke volume; SW, stroke volume variability; TAptransversus abdominis plane; UCLA, University of California, Los Angles.

Figure 2.

Interrupted time series plots of morphine equivalent intraoperatively and rate of opioid prescription at discharge. Cl indicates confidence interval; ERAS, enhanced recovery after surgery; IV, intravenous; MS04, morphine equivalent in milligram.

Figure 3.

Forest plot of subgroup analysis for the incidence of opioid prescription at discharge from the hospital. Cl indicates confidence interval; MOE, morphine equivalents.