Colorectal surgery patients use fewer opioids, report less pain with enhanced recovery after surgery

Colorectal surgery patients who were a part of an enhanced recovery after surgery (ERAS) program had less pain, while using nearly half as many opioids, according to research being presented at the ANESTHESIOLOGY 2019 annual meeting.

ERAS protocols focus on reducing the use of opioids while minimizing pain, expediting patient recovery, decreasing complications and shortening hospital length of stay. Championed by physician anesthesiologists, ERAS is an aspect of the Perioperative Surgical Home, a comprehensive suite of services, resources and tools that support team-based care.

In the study, opioid use after colorectal surgery was reduced by providing alternatives, such as ketorolac, acetaminophen, gabapentin and ketamine, as well as by managing patient expectations, e.g., letting them know that some pain is normal and to be expected after surgery.

"Patients attend a pre-surgical ERAS clinic where a multi-disciplinary team prepares them and their families for a successful recovery through pre-surgical education, including helping them understand what to expect before, during and after surgery," said Bradley Larson, M.D., lead author of the study and resident physician anesthesiologist at Beaumont Hospital, Royal Oak, Michigan. "This study suggests ERAS programs can decrease the amount of opioids patients use after surgery, while better managing pain."

In the study, researchers compared opioid use and pain levels in 181 patients who had colorectal surgery under the ERAS program to 66 patients who had colorectal surgery prior to the implementation of ERAS. A retrospective chart review was conducted to determine both opioid and non-opioid use during the perioperative period starting on postoperative day zero through day three.

The ERAS group had:

• 45% fewer opioids during surgery
• 44% fewer opioids immediately after surgery
• 42% fewer opioids three days after surgery, all of which were statistically significant

Further, ERAS patients were much more likely to receive alternatives to opioids:

• 75% of ERAS patients received ketorolac, while 17% received it pre-ERAS
• 97% of ERAS patients received acetaminophen vs. 56% pre-ERAS patients
• 68% of ERAS patients received gabapentin vs. 6% pre-ERAS patients
• 82% of ERAS patients received ketamine vs. 4% pre-ERAS patients

Patients also answered questions regarding their pain immediately after surgery on a scale from 0 (no pain) to 10 (worse pain imaginable). The ERAS group reported an average score of 5.12, which was significantly less than the average score of 6.45 in the pre-ERAS group.

Most prior research on ERAS and similar programs have focused on cost, complications and resource utilization, said Dr. Larson. For this study, researchers wanted to assess the impact managing patient expectations and alternative forms of pain medication would have on opioid use.

"Through ERAS, patients are educated regarding the appropriate level of pain to anticipate after surgery and are more willing to accept that some form of postoperative pain is normal and to be expected," he said. "Therefore, they are less likely to request additional medication to attempt to fully alleviate their pain, which leads to decreased opioid consumption."