Gabapentin Decreases Narcotic Usage: Enhanced Recovery after Surgery Pathway in Free Autologous Breast Reconstruction

Abstract

Background:The opioid crisis is public health emergency, in part due to physician prescribing practices. As a result, there is an increased interest in reducing narcotic use in the postsurgical setting.Methods:From January 1, 2018, to October 31, 2018, we employed a multidisciplinary, multimodal Enhanced Recovery After Surgery (ERAS) pathway abdominally based free tissue transfer involving the rectus. Preoperative, intraoperative, and postoperative nonnarcotic modalities were emphasized. Factors in reducing narcotic consumption, pain scores, and antiemetic use were identified.Results:Forty-two patients were included for a total of 66 free flaps, with a 98.4%(65/66) success rate. Average postoperative in-hospital milligram morphine equivalent (MME) use was 37.5, but decreased 85% from 80.9 MME per day to 12.9 MME per day during the study period. Average pain scores and antiemetic doses also decreased. Postoperative gabapentin was associated with a significant 59.8 mg decrease in postoperative MME use, 21% in self-reported pain, and a 2.5 fewer doses of antiemetics administered but increased time to ambulation by 0.89 days. Postoperative acetaminophen was associated with a significant 3.0 point decrease in self-reported pain.Conclusions:This study represents our early experience. A shift in the institutional mindset of pain control was necessary for adoption of the ERAS protocol. While the ERAS pathway functions to reduce stress and return patients to homeostasis following surgery, postoperative gabapentin resulted in the greatest reduction in postoperative opioid use, self-reported pain, and postoperative nausea vomiting compared to any other modality.

Preoperative Gabapentin Administration and Its Impact on Postoperative Opioid Requirement and Pain in Sinonasal Surgery

“…7,11,12,15 Concomitant chronic comorbidities, including mood or migraine disorder (which can affect baseline pain perception), are often not reported. 5,8,10,23,24…”

“…There are also differences between the present study and nonotolaryngologic studies that showed a perioperative benefit of gabapentin on postoperative pain scores and opioid requirements. First, nonotolaryngologic study patients often undergo inpatient procedures, with longer surgery times and more baseline anticipated pain 5 , 8 . These studies may employ multiple preoperative medications, which can make it difficult to assess the independent effect of gabapentin 5 .…”

“…Multiple studies from the spine, abdominal, orthopedic, and urogynecologic literature demonstrate the efficacy of perioperative gabapentin in reducing postoperative opioid need as well as postoperative pain. 5-9…”

Does An ERAS Protocol Reduce Postoperative Opiate Prescribing in Plastic Surgery?

“…To preemptively treat perioperative pain, patients received a single preoperative dose of oral acetaminophen and gabapentin (dosed for age) and regimented postoperative oral acetaminophen (scheduled administration for 24 hours followed by as-needed dosing), low-dose twice-daily gabapentin for 7–14 days, ibuprofen as needed, and oxycodone when necessary ( Table 1 ). 19 , 20 , 21 , 22 , 23 Patients who were undergoing mastectomy with immediate reconstruction underwent preoperative paravertebral blocks, which was the standard of care in the practice prior to the implementation of this ERAS protocol. 24 Operative cases performed included: breast reduction, mastopexy, immediate prosthetic breast reconstruction, revision breast reconstruction, breast augmentation, panniculectomy, abdominoplasty, and gender-affirming chest/breast surgery.…”

A Narrative Review on Perioperative Pain Management Strategies in Enhanced Recovery Pathways—The Past, Present and Future

“…Gabapentinoids (e.g., gabapentin and pregabalin) are anticonvulsants that have been used to treat neuropathic pain. Despite their documented sedative and central depressive effects, they are currently strongly recommended in ERAS pathways as earlier randomized controlled trials and meta-analyses demonstrated potent perioperative analgesic and opioid-sparing effects in multiple surgical domains including gynecologic, breast, orthopedic, and spine surgery [36][37][38][39][40][41]. However, the optimal dosage, timing and duration of perioperative gabapenintoid therapy has not been clearly demonstrated, and some argue that clinical effects of gabapentinoids may actually secondary to their sedative properties [42,43].…”