Opioid Prescribing Habits Following Implementation of Enhanced Recovery After Surgery (ERAS) in Patients Undergoing Major Urologic Reconstruction
Nadia V. Halstead, MD, MPH, Sarah L. Hecht, MD, Peter J. Boxley, BA, Megan A. Brockel, MD, Kyle O. Rove, MD.
University of Colorado School of Medicine & Children's Hospital of Colorado, Aurora, CO, USA.
With increasing awareness of the opioid epidemic, there is a push for providers to minimize opioid prescriptions after surgery. Enhanced recovery after surgery (ERAS) pathways include minimization of opioid analgesia in favor of non-opioid alternatives and regional anesthesia for postoperative pain control. In 2014, our center implemented an ERAS pathway for children undergoing urologic reconstructive surgery. This led to significantly lower intra- and postoperative use of opioids, among other benefits. It is unclear whether the decreased in-hospital opioid requirements affected opioid prescribing practices or patient needs upon discharge. We hypothesized that ERAS would result in fewer opioid prescriptions.
An IRB-approved retrospective review was performed of all patients who underwent bladder augmentation, creation of a continent catheterizable channel, bladder neck reconstruction or closure, or revision of prior reconstructive procedures at our tertiary care facility from October 2011 to August 2017. Patients were divided into historical and ERAS cohorts based on whether surgery occurred before or after ERAS implementation. The Colorado Physician Drug Monitoring Program (PDMP) was used to track filling of post-operative opioid prescriptions. Demographic information, intraoperative details, perioperative analgesia, postoperative opioid needs, and opioid prescription details were recorded. Median values, interquartile ranges, and non-parametric statistical tests were calculated with a significance level of 0.05. Multivariate logistic and linear regression analyses were performed to identify predictors of outcome variables of interest.
A total of 190 urologic reconstructive surgeries were included in our analysis, 92 historical and 98 after ERAS implementation. The patient cohorts were demographically similar. The percentage of patients who received an opioid prescription and those who subsequently filled them as confirmed by querying the PDMP was significantly higher in the ERAS cohort (93.9% vs 82.6%, p=0.015; 76.1% vs 57.9%, p=0.012). There were no differences, however, in prescription total morphine milligram equivalents (MME) by body weight (p=0.164) or opioid days supplied (p=0.567) between the two groups. The number of patients who requested and received additional opioid prescriptions (within 90 days) also did not vary between the two groups (19.4% ERAS vs 17.4% historical, p=0.723). There were differences in prescribing habits by training level. Urology residents prescribed higher total MME by weight compared to pediatric urology fellows (2.9 mg/kg vs 1.5 mg/kg, p=0.001). Interestingly, patients had a lower likelihood of receiving a postoperative prescription if they were listed as self pay (odds ratio 0.0154, 95% confidence interval 0.0012-0.1890, p=0.001).
There was an unexpected increase in post-operative opioid prescriptions written and filled at discharge following implementation of an ERAS protocol for major urologic reconstructive surgery. Decreased length of stay may have increased provider concern about pain control at home. Understanding factors affecting opioid prescribing practices and patient needs are important prior to designing interventions to minimize opioids after surgery.
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