Key learnings from early adopters of opioid-free ERAS protocols

Post-surgery recovery programs with opioid-sparing and opioid-free protocols are increasingly being leveraged to prevent the risk of opioid addiction and improve pain management for patients.

During an Aug. 15 webinar sponsored by Mallinckrodt Pharmaceuticals and hosted by Becker's Hospital Review, TJ Gan, MD, professor and chairman in the department of anesthesiology for Stony Brook (N.Y.) University Renaissance School of Medicine, discussed the evolution of pain management techniques, the benefits of using enhanced recovery after surgery protocols and opioid-free multimodal analgesia in the surgical setting, and described key learnings from early adopters of opioid-free ERAS protocols.

Pain management techniques: Past, present and future

To better address post-surgical pain, recovery protocols are continually evolving, Dr. Gan explained.  

At one point, opioids were the standalone method of managing acute pain in hospitals post-surgery. However, in recent years, methods that rely on a combination of therapies rather than opioids exclusively have been shown to be safer and more effective at improving clinical outcomes, Dr. Gan said. 

In a cross-sectional cohort study of more than 500,000 hip replacement patients published in the journal of Anesthesiology in 2018, patients treated with multimodal pain management instead of opioid monotherapy experienced a 19 percent decrease in gastrointestinal complications, a 19 percent reduction in opioid prescriptions post-discharge and a 12 percent decrease in length of stay.

"The study reveals multimodal pain management analgesia should be the cornerstone of our pain management strategy," Dr. Gan said.

While multimodal approaches to pain management — which may or may not include some use of opioids — can help improve outcomes and ultimately reduce the cost of care post-surgery, there is a case for opioid-free therapy options, Dr. Gan said.

An opioid-free ERAS protocol aims to reduce the incidence of opioid-related adverse events, cutting opioid-induced hyperalgesia rates, lowering the risk of opioid addiction and improving discharge time.

"We should start to think opioid-free in intraoperative, post-operative and beyond … to improve outcomes and lower the risk of persistent opioid use postoperatively," Dr. Gan said.

Using opioid-free techniques in surgeries is still new. However, some healthcare organizations have begun to implement opioid-free ERAS protocols.  

Here are three key learnings from the early adopters of opioid-free ERAS protocols:

1. Set patient pain expectations early. It is important to educate the patient right away about the short and long-term benefits of using an opioid-free approach in their procedure, Dr. Gan explained. If patients know they may experience some pain but fewer side effects, their overall experience will likely be improved. "The patient needs to understand the aim is not to have zero out of 10 pain," he said.

2. Generate stakeholder, institutional buy-in. The surgical journey takes a patient through various departments in the hospital, each with their own focus and personnel. This means that opioid-free anesthesia alone may not reduce patients' opioid exposure as they may receive an opioid-based analgesia or may be prescribed opioids at discharge. "Limiting opioid exposure is a full team effort, and stakeholder buy in is essential at all stages of ERAS in order to remain opioid free," Dr. Gan said.

3. Understand an opioid-free strategy is possible. Opioid-free ERAS can be successfully implemented with institutional buy-in, careful planning and cooperation, Dr. Gan explained. Hospitals should begin to implement opioid-sparing and opioid-free ERAS protocols to improve patient outcomes and limit the risk of opioid addiction.

To learn about an example of an opioid-free ERAS protocol, the benefits of opioid-free analgesia and the evolution of pain management, listen to the webinar here.

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The challenges of lowering opioid prescriptions
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