K. E. Hudak1, L. E. Goss2, R. K. Burton3, P. K. Patel1, E. A. Dasinger2, G. D. Kennedy2, J. A. Cannon2, M. S. Morris2, J. S. Richman2, D. I. Chu2 1University Of Alabama at Birmingham,School Of Medicine,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Department Of Gastrointestinal Surgery,Birmingham, Alabama, USA 3University Of Alabama at Birmingham,School Of Public Health,Birmingham, Alabama, USA
Introduction: The excess utilization of opioids after surgery is common and may contribute to the national opioid epidemic. Enhanced Recovery After Surgery (ERAS) pathways have been shown to decrease in-hospital opioid utilization, but their effect on post-discharge opioid utilization is unclear. We hypothesized that patients undergoing ERAS for colorectal surgery would have decreased opioid utilization on discharge and at one-year post-discharge.
Methods: A single-institution ERAS database was used to identify all patients undergoing colorectal surgery in 2015. ERAS patients were then matched by sex, race, age, indication, and procedure with pre-ERAS patients from 2013-14 to create a comparison group. Patient/procedure-level characteristics were included. Excluded were patients who died within one year of surgery, long-term dependent opioid users, and opioid users above the 99th percentile of oral morphine equivalents (OME). Outcomes evaluated included OME at discharge, total OME within 1-year, OME per pill (OME/P) at discharge, opioid type, and pill counts. Variables with p<0.05 on bivariate comparisons were included in adjusted linear models.
Results: Of 395 patients included in this study, 89.6% were prescribed an opioid on discharge. Pre-ERAS (n=197) and ERAS (n=198) patients were similar by matched characteristics and smoking status, ASA class, hypertension and diabetes. Compared to pre-ERAS patients, ERAS patients had more minimally invasive surgeries (43.4% vs. 32.5%), more ostomies (38.9% vs. 25.9%) and had lower rates of baseline opioid use (15.2% vs. 29.4%) (p<0.03). More ERAS patients were discharged with no opioids compared to pre-ERAS patients (13.1% vs. 7.6%, p=0.07). Among those discharged with opioids, ERAS patients received an average of 403 OME and 60.6 pills vs. 343 OME and 46.9 pills for pre-ERAS (p<0.03 for all). However, the OME/P at discharge was significantly lower for ERAS (6.9 vs. 7.6, p<0.01), which remained after adjustment for covariate differences (7.0 vs 7.9, p=0.01). ERAS patients used more low-OME medications, such as tramadol (35.9% vs. 0%, p<0.001) and were prescribed fewer high-OME medications containing hydrocodone or oxycodone (37.9% vs. 72%, p<0.01). At one-year post-discharge, ERAS patients received fewer additional high-OME prescriptions (34.3% vs. 43.7%, p<0.01).
Conclusion: ERAS modifies post-discharge opioid utilization for patients undergoing colorectal surgery. On discharge, more patients undergoing ERAS required no opioids and at one year, ERAS patients required less opioid prescriptions. While ERAS patients discharged with opioids did receive more OMEs overall, these OMEs were distributed over more pills and ERAS patients actually received more low-potency (low OME) pills, accounting for a lower OME/P ratio. These findings suggest a potential role for ERAS in reducing post-discharge opioids utilization and an additional need to standardize post-discharge prescriptions patterns.