Postoperative Opioid Use Before and After Enhanced Recovery After Surgery Program Implementation

Liu, Vincent X; Eaton, Abigail; Lee, Derrick C; Reyes, Vivian; Paulson, Shirley; Campbell, Cynthia I.; Avins, Andy; Parodi, Stephen

doi:10.1097/sla.0000000000003409

Cited by 13 publications

(10 citation statements)

References 10 publications

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“…Liu et al (2019) implemented an ERAS protocol targeting two patient populations (2468 elective colorectal and 3885 emergent hip fracture patients) with specific multimodal non-opioid adjuncts and followed patients for up to 1 year after surgery. Using pharmacy dispensing records it was reported that implementation of the ERAS protocol was associated with more than a 20% reduction in opioid refills 3 months to 1 year after surgery [ 12 ]. Razi et al (2020) investigated an Enhanced Recovery after Thoracic Surgery (ERATS) protocol for patients undergoing thoracotomies and robotic thoracoscopies which focused on a multimodal pain management strategy including the use of opioid-sparing analgesics and regional anesthesia.…”

Section: Perioperative Protocols/clinical Pathwaysmentioning

confidence: 99%

Reducing New Persistent Opioid Use After Surgery: A Review of Interventions

Burns

Urman

Pian

et al. 2021

Curr Pain Headache Rep

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Purpose of Review This review aims to summarize interventions used in the perioperative period to reduce the development of new persistent postoperative opioid use in opioid-naïve patients. Recent Findings The development of new persistent opioid use after surgery has recently been identified as a common postoperative complication. The existing literature suggests that interventions across the continuum of care have been shown to decrease the incidence of new persistent postoperative opioid use. Specific preoperative, intraoperative, and postoperative interventions will be reviewed, as well as the use of clinical pathways and protocols that span throughout the perioperative period. Common to many of these interventions include the use of multimodal analgesia throughout the perioperative period and an emphasis on a patient-centered, evidence-based approach to the perioperative pain management plan. Summary While the incidence of new persistent postoperative opioid use appears to be high, the literature suggests that there are both small- and large-scale interventions that can be used to reduce this. Technological advances including prescription monitoring systems and mobile applications have enabled studies to monitor opioid consumption after discharge. Interventions that occur preoperatively, such as patient education and expectation setting regarding postoperative pain management, and interventions that occur postoperatively, such as the implementation of procedure-specific, evidence-based prescribing guidelines and protocols, have been shown to reduce post-discharge opioid consumption. The use of multimodal analgesia and opioid-sparing adjuncts throughout the perioperative period is central to many of these interventions and has essentially become standard of care for management of perioperative pain.

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Section: Perioperative Protocols/clinical Pathwaysmentioning

confidence: 99%

Reducing New Persistent Opioid Use After Surgery: A Review of Interventions

Burns

Urman

Pian

et al. 2021

Curr Pain Headache Rep

View full text Add to dashboard Cite

show abstract

“…Our counterfactual predictions contextualize the magnitude of effects stemming from typical clinically relevant incremental doses of fentanyl and hydromorphone . The predicted percentage reduction in hospital-administered MME, opioid prescriptions through 180 days, and new persistent opioid use after an incremental 100-µg dose of fentanyl appear comparable to the outcomes of major interventions in opioid prescribing practices . This same dose of fentanyl also predicted a significant reduction in length of stay.…”

Section: Discussionmentioning

confidence: 72%

“…34,35 The predicted percentage reduction in hospital-administered MME, opioid prescriptions through 180 days, and new persistent opioid use after an incremental 100-μg dose of fentanyl appear comparable to the outcomes of major interventions in opioid prescribing practices. [36][37][38][39] This same dose of fentanyl also predicted a significant reduction in length of stay. While opioid prescribing practices shift toward limitation, our counterfactual predictions would seem to reflect a reduction in the intrinsic need for opioids after surgery attained by improved control of intraoperative nociception.…”

Section: Counterfactual Predictionsmentioning

confidence: 99%

Association of Intraoperative Opioid Administration With Postoperative Pain and Opioid Use

et al. 2023

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ImportanceOpioids administered to treat postsurgical pain are a major contributor to the opioid crisis, leading to chronic use in a considerable proportion of patients. Initiatives promoting opioid-free or opioid-sparing modalities of perioperative pain management have led to reduced opioid administration in the operating room, but this reduction could have unforeseen detrimental effects in terms of postoperative pain outcomes, as the relationship between intraoperative opioid usage and later opioid requirements is not well understood.ObjectiveTo characterize the association between intraoperative opioid usage and postoperative pain and opioid requirements.Design, Setting, and ParticipantsThis retrospective cohort study evaluated electronic health record data from a quaternary care academic medical center (Massachusetts General Hospital) for adult patients who underwent noncardiac surgery with general anesthesia from April 2016 to March 2020. Patients who underwent cesarean surgery, received regional anesthesia, received opioids other than fentanyl or hydromorphone, were admitted to the intensive care unit, or who died intraoperatively were excluded. Statistical models were fitted on the propensity weighted data set to characterize the effect of intraoperative opioid exposures on primary and secondary outcomes. Data were analyzed from December 2021 to October 2022.ExposuresIntraoperative fentanyl and intraoperative hydromorphone average effect site concentration estimated using pharmacokinetic/pharmacodynamic models.Main Outcomes and MeasuresThe primary study outcomes were the maximal pain score during the postanesthesia care unit (PACU) stay and the cumulative opioid dose, quantified in morphine milligram equivalents (MME), administered during the PACU stay. Medium- and long-term outcomes associated with pain and opioid dependence were also evaluated.ResultsThe study cohort included a total of 61 249 individuals undergoing surgery (mean [SD] age, 55.44 [17.08] years; 32 778 [53.5%] female). Increased intraoperative fentanyl and intraoperative hydromorphone were both associated with reduced maximum pain scores in the PACU. Both exposures were also associated with a reduced probability and reduced total dosage of opioid administration in the PACU. In particular, increased fentanyl administration was associated with lower frequency of uncontrolled pain; a decrease in new chronic pain diagnoses reported at 3 months; fewer opioid prescriptions at 30, 90, and 180 days; and decreased new persistent opioid use, without significant increases in adverse effects.Conclusions and RelevanceContrary to prevailing trends, reduced opioid administration during surgery may have the unintended outcome of increasing postoperative pain and opioid consumption. Conversely, improvements in long-term outcomes might be achieved by optimizing opioid administration during surgery.

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“…KPNC's use of IS to systematically improve sepsis care fostered new programs designed to bring evidence-based care to critically ill patients. Using a similar approach, KPNC focused on Clostridium difficile and hospital-acquired infection prevention (160,175,176), mechanical ventilation liberation (177), delirium prevention (178,179), patient mobility (177,180), enhanced recovery after surgery (180-182), regional tele-stroke management (183), conservative blood transfusion management (184)(185)(186), opiate exposure reduction (182,187), palliative care management (188), readmission prevention (189,190), and prevention of inpatient deterioration through early warning systems (191)(192)(193). Each of these efforts leveraged: 1) QI initiatives and iterative improvement cycles; 2) granular and high-quality data and metrics available through the EHR; 3) change management approaches bringing together diverse content experts, clinicians, and stakeholders; 4) consistent aims and messaging via a governance structure aligning both regional and local leaders; and 5) the delivery of patient-centered care.…”

Section: Kaiser Permanente Northern Californiamentioning

confidence: 99%