A Randomized Controlled Trial Examining the Impact of an Anorectal Surgery Multimodal Enhanced Recovery Program on Opioid Use

Abstract

Background: Anorectal cases may be a common gateway to the opioid epidemic. Opioid reduction is inherent in enhanced recovery after surgery (ERAS) protocols, but little work has evaluated ERAS in these cases. Objective: To determine if ERAS could reduce postoperative opioid utilization in ambulatory anorectal surgery without sacrificing patient pain or satisfaction. Methods: A randomized controlled trial assigned ambulatory anorectal patients to ERAS (experimental) or routine care (surgeon's choice) for pain management (control) over 30-days postoperatively. Primary outcome was overall days of opioid use. Secondary outcomes included pain and satisfaction scores over multiple time points and new persistent opioid use. The Visual Analog Scale, Functional Pain Scale, and EQ-5D-3L measured patientreported pain and satisfaction. Univariate analysis compared outcomes overall and at individual time points. Two-way mixed ANOVA evaluated pain and satisfaction measures between groups and over time. Results: Thirty-two patients were randomized into each arm (64 total). The control group consumed significantly more opioids after discharge (median 121.3MME vs 23.5MME, P < 0.001). Significantly more control patients requested additional narcotics (P ¼ 0.004), made unplanned calls (P ¼ 0.009), and had unplanned clinic visits (P ¼ 0.003). The control group had significantly more days on opioids (mean 14.4 vs 2.2, P < 0.001). Three control patients (9.4%) versus no experimental patients had new persistent opioid use. The mean global health, EQ5D-3L, Visual Analog Scale, and Functional Pain scores were comparable between groups over time. Conclusions: An ERAS protocol in ambulatory anorectal surgery is feasible, and resulted in reduced opioid use, and healthcare utilization, with no difference in pain or patient satisfaction. This challenges the paradigm that extended opioids are needed for effective postoperative pain management.

Perioperative pain optimization in the age of the opioid epidemic

“…Seu et al [17] observed similar findings via a 36% reduction in total inpatient opioid use and a 57% reduction in total outpatient opioid use during bariatric surgery when ERAS protocols were implemented. Furthermore, a randomized control trial on ambulatory anorectal surgery found that an ERAS protocol reduced opioid use and healthcare utilization with no difference in pain or patient satisfaction [18]. As the highest number of postoperative opioid prescriptions are written by surgical specialists [19], the above findings also highlight the importance of involving surgeons in the shared responsibility of ensuring implementation and efficacy of ERAS protocols and other MMA programs.…”

Effect of intracutaneous pyonex therapy on postoperative pain management following perianal surgery: A systematic review and meta-analysis

“…Patients with perianal disorders seek treatment including surgical interventions for aggravated symptoms [2]. Most patients experience mild to moderate pain during the perioperative period of perianal surgery, whereas some experience severe postoperative pain [3,4]. Postoperative pain is not only a common cause of delayed discharge but also one of the leading reasons for readmission of patients after perianal surgery [5,6].…”