June 20, 2019

Helping surgical patients avoid long-term use of opioids

Can improved management of hospitalized patients lead to less painkiller use? Kaiser Permanente study shows promising results.

Surgical patients who get fewer opioids and more alternative pain control while hospitalized are less likely to continue using opioid painkillers 6 months to 1 year later. That’s according to a new analysis of data from an initiative carried out in Kaiser Permanente hospitals across Northern California.

The analysis, titled “Postoperative Opioid Use Before and After Enhanced Recovery After Surgery [ERAS] Program Implementation,” was published online June 20, 2019, in the Annals of Surgery.

ERAS is designed to make surgery easier on patients by encouraging them to eat well in preparation, get moving soon after, use fewer opioids and more alternatives to control pain, and be engaged in their own recovery.

Lead author Vincent Liu, MD, PhD, an investigator with the Kaiser Permanente Northern California Division of Research, explains why he and his colleagues wanted to further explore the ERAS data to find out how the surgical patients fared during the months after they left the hospital.

Vincent Liu, MD, PhD, investigator with Kaiser Permanente Northern California Division of Research
Vincent Liu, MD, PhD

First, what is ERAS?

ERAS is a standardized approach to help patients prep for surgery and manage their pain and mobility so they can recover more quickly. Surgery has a big impact on all aspects of a person’s body and mind. Thus, in the same way someone would prep for a marathon, before surgery, patients also load up on calories rather than keeping with the tradition of simply avoiding food. ERAS also applies modern approaches to pain control, using fewer opioids in favor of alternatives such as local anesthetic and scheduled acetaminophen where possible.

A version of ERAS was adopted by Kaiser Permanente’s 21 Northern California hospitals in 2014 and rolled out over time, which allowed us to study what happened to patients before and after ERAS was rolled out.

Why did you want to learn more about the patients’ later painkiller use?

Surgery is one major way that people are introduced to opioids and some people may have trouble stopping once their surgical pain recedes. If we can reduce unnecessary exposure to opioids in the hospital either with lower doses or effective alternatives such as local anesthetic, perhaps we can help some people avoid a difficult battle with opioid use disorder.

What did you learn?

We compared groups of surgical patients who were cared for before and after ERAS began in our hospitals and found a dramatic decrease in long-term opioid use after ERAS. More than 30% of patients before ERAS were using opioids 6 months to 1 year after surgery, but under 10% did after ERAS. That tells us the program is making a difference.

Another important finding was that the benefits of reduced opioid dosages extended to other surgical patients who were having similar surgeries but were not subject to the ERAS protocol. These non-ERAS patients had similar reductions in long-term opioid use. We’re not sure of the exact reason for this, but I suspect that clinicians find it difficult not to use these enhanced recovery pathways for all of their surgical patients once they are familiar with them.

Were there any surprises?

The improvements in long-term opioid use did not necessarily extend to patients who were already using opioids before they came in for a surgical procedure. This means there is still an opportunity to work with patients using opioids before surgery to find ways to ensure adequate pain control that minimizes the risks of overuse.

How is ERAS being used today?

Since ERAS was rolled out across our system for patients undergoing colon and hip fracture surgery in 2014, we have now rolled it out to all inpatient surgeries. We want to make sure that all of our surgical patients experience the same benefits of ERAS – fewer complications and reduced opioid use – we’ve seen in our initial groups.

This latest study follows up on 2017 research published in JAMA Surgery by Kaiser Permanente investigators that found shorter lengths of stay and fewer complications after the implementation of the ERAS program.