The Association between Implementation an Enhanced Recovery after Cesarean Pathway with Standardized Discharge Prescriptions and Opioid Use and Pain Experience after Cesarean Delivery

Objective This study was aimed to evaluate opioid use after cesarean delivery (CD) and to assess implementation of an enhanced recovery after CD (ERAS-CD) pathway and its association with inpatient and postdischarge pain control and opioid use. Study Design We conducted a baseline survey of women who underwent CD from January to March 2017 at a single, urban academic hospital. Patients were called 5 to 8 days after discharge and asked about their pain and postdischarge opioid use. An ERAS-CD pathway was implemented as a quality improvement initiative, including use of nonopioid analgesia and standardization of opioid discharge prescriptions to ≤25 tablets of oxycodone of 5 mg. From November to January 2019, a postimplementation survey was conducted to assess the association between this initiative and patients' pain control and postoperative opioid use, both inpatient and postdischarge. Results Data were obtained from 152 women preimplementation (PRE) and 137 women post-implementation (POST); complete survey data were obtained from 102 women PRE and 98 women POST. The median inpatient morphine milligram equivalents consumed per patient decreased significantly from 141 [range: 90–195] PRE to 114 [range: 45–168] POST (p = 0.002). On a 0- to 10-point scale, median patient-reported pain scores at discharge decreased significantly (PRE: 7 [range: 5–8] vs. POST 5 [range: 3–7], p < 0.001). The median number of pills consumed after discharge also decreased significantly (PRE: 25 [range: 16–30] vs. POST 17.5 [range: 4–25], p = 0.001). The number of pills consumed was significantly associated with number prescribed (p < 0.001). The median number of leftover pills and number of refills did not significantly differ between groups. Median patient-reported pain scores at the week after discharge were lower in the POST group (PRE: 4 [range: 2–6] vs. POST 3[range: 1–5], p = 0.03). Conclusion Implementing an ERAS-CD pathway was associated with a significant decrease in inpatient and postdischarge opioid consumption while improving pain control. Our data suggest that even fewer pills could be prescribed for some patients. Key Points

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Enhanced Recovery After Surgery Pathway for Cesarean Delivery: Effect on Opioid Use and Pain Scores [5K]

Obstetrics and Gynecology ◽

10.1097/01.aog.0000558858.22192.c3 ◽

2019 ◽

Vol 133 (1) ◽

pp. 119S-119S ◽

Cited By ~ 1

Author(s):

Emily E. Fay ◽

Carlos C. Delgado ◽

Jane Hitti ◽

Leah Savitsky ◽

Elizabeth Mills ◽

...

Keyword(s):

Cesarean Delivery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Opioid Use ◽

Pain Scores

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Multimodal Analgesia Protocol after Head and Neck Surgery: Effect on Opioid Use and Pain Control

Otolaryngology ◽

10.1177/0194599819841885 ◽

2019 ◽

Vol 161 (3) ◽

pp. 424-430 ◽

Cited By ~ 9

Author(s):

Eugenie Du ◽

Zainab Farzal ◽

Elizabeth Stephenson ◽

April Tanner ◽

Katherine Adams ◽

...

Keyword(s):

Head And Neck ◽

Pain Control ◽

Neck Surgery ◽

Multimodal Analgesia ◽

Quality Improvement Initiative ◽

Opioid Use ◽

Protocol Implementation ◽

Pain Scores ◽

Before And After ◽

Average Pain

Objective To assess the effect that implementation of a multimodal analgesic plan has on opioid requirements and pain control in head and neck (H&N) surgery patients. Study Design Prospective cohort. Setting Tertiary academic hospital. Subjects and Methods An institutional review board (IRB)–approved quality improvement initiative was undertaken to implement a multimodal analgesic protocol for all admitted H&N surgery patients starting November 2017. Postprotocol data from January to May 2018 were compared to preprotocol data from May to October 2017. Data were obtained from the electronic health records as well as through preoperative and postoperative surveys. Average pain scores and opioid use in morphine milligram equivalents (MMEs) before and after protocol implementation were compared. Results In total, 139 postprotocol patients were compared to 89 preprotocol patients. The adjusted MMEs in the first 24 hours after surgery decreased significantly from 93.7 mg to 58.6 mg ( P = .026) with protocol implementation. When averaged over the length of stay (MME/hospital day), the change was no longer statistically significant (57.9 vs 46.8 mg, P = .211). The average pain score immediately after surgery and on day of discharge did not change with protocol implementation. Conclusion Implementation of a multimodal analgesia plan reduced opioid use immediately after surgery but not over the course of hospitalization without any change in reported pain scores. This study shows that multimodal opioid-sparing analgesia after H&N surgery is feasible. Future studies are needed further refine the optimal analgesic strategy for H&N patients and assess the long-term efficacy, safety, and cost of such regimens.

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Implementation of an Enhanced Recovery after Surgery Pathway to Reduce Inpatient Opioid Consumption after Cesarean Delivery

American Journal of Perinatology ◽

10.1055/s-0041-1732450 ◽

2021 ◽

Author(s):

Jared L. Tepper ◽

Olivia M. Harris ◽

Jourdan E. Triebwasser ◽

Stephanie H. Ewing ◽

Aasta D. Mehta ◽

...

Keyword(s):

Length Of Stay ◽

Cesarean Delivery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Opioid Consumption ◽

Quality Improvement Initiative ◽

Adjusted Relative Risk ◽

Opioid Use ◽

Opioid Prescription ◽

The Impact

Objective Opioid prescription after cesarean delivery is excessive and can lead to chronic opioid use disorder. We assessed the impact of an enhanced recovery after surgery (ERAS) pathway on inpatient opioid consumption after cesarean delivery. Study Design An ERAS pathway was implemented as a quality improvement initiative in December 2019. Preintervention (PRE) data were collected from March to May 2019 to assess baseline opioid consumption. Postintervention (POST) data were collected from January to March 2020. The primary outcome was inpatient postoperative opioid consumption in morphine milligram equivalents (MME). Secondary outcomes included the consumption of any opioids, postpartum length of stay, and opioid prescription at discharge. Results A total of 92 women were in the PRE group and 91 were in the POST group. Inpatient opioid consumption decreased by 87.3% from PRE to POST, from 124.7 (interquartile range [IQR]: 10–181.6) MME to 15.8 (IQR: 0–75) MME (p < 0.001). There was no difference in median postpartum length of stay (3.4 days PRE vs. 3.3 days POST; p = 0.12). The proportion of women who did not consume any opioids increased by 75.4% from PRE to POST (p = 0.02). The proportion of women discharged with an opioid prescription decreased by 25.6% from PRE to POST (p = 0.007), despite no formal change to prescribing practices. After adjustment for differences in race/ethnicity and gravidity, there was still a reduction in total inpatient opioid consumption (p < 0.001) and an increase in the proportion of women not consuming any opioids (adjusted relative risk (RR): 2.14, 95% confidence interval [CI]: 1.18–3.87), but the difference in rate of prescription of opioids at discharge was no longer statistically significant (adjusted RR: 0.70, 95% CI: 0.48–1.02). Conclusion Adoption of an ERAS pathway for cesarean delivery resulted in a marked reduction in inpatient opioid consumption. Such a pathway can be implemented across institutions and may be a powerful tool in combating the opioid epidemic. Key Points

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A Prospective Cohort Study Towards Improving Enhanced Recovery After Cesarean (ERAC) Pathways.

10.1101/2021.11.07.21265950 ◽

2021 ◽

Author(s):

Liviu Cojocaru ◽

Autusa Pahlavan ◽

Suzanne Alton ◽

Martha Coghlan ◽

Hyunuk Seung ◽

...

Keyword(s):

Cohort Study ◽

Postpartum Depression ◽

Prospective Cohort Study ◽

Prospective Cohort ◽

Enhanced Recovery ◽

Postoperative Recovery ◽

Opioid Use ◽

Pain Scores ◽

Number Of Patients ◽

Patient Reported

Background: Enhanced Recovery After Surgery (ERAS) or, more specifically for obstetrics, Enhanced Recovery after Cesarean (ERAC) pathways have emerged as a multidisciplinary standardized bundled care approach to improve maternal outcomes. Despite this, ERAS pathways have not been fully embraced in obstetrics, leaving significant space for improvement. Moreover, most of the studies have not extended ERAC pathways to specific populations such as opioid-naive patients, patients with postpartum depression, or patients receiving Magnesium Sulfate, allowing aforementioned confounders to affect the magnitude of the measured outcome. Objectives: To evaluate whether an Enhanced Recovery After Cesarean (ERAC) pathways reduces inpatient and outpatient opioid use, pain scores and improves the indicators of postoperative recovery. Furthermore, the specifics of our protocol are intended to decrease the knowledge gaps in ERAC pathways. Study design: This is a prospective cohort study of all patients older than 18 undergoing an uncomplicated cesarean delivery (CD) at an academic medical center. We excluded CD done under general anesthesia, those complicated by massive transfusion events, bowel injury, requiring recovery in the intensive care unit, and skin incision other than Pfannenstiel. Additionally, we excluded patients with chronic pain disorders, chronic opioid use, acute postpartum depression, or mothers whose neonate demised before their discharge. Lastly, we excluded non-English and non-Spanish speaking patients. Our study compared the outcomes in patients before (pre-ERAC) and after (post-ERAC) implementation of an ERAC pathways. Primary outcomes were inpatient morphine milligram equivalent (MME) use and the patient's delta pain scores (patient's reported goal subtracted from patient's pain score). Secondary outcomes were outpatient MME prescriptions as well as indicators of postoperative recovery (e.g., fasting time, time to feeding, time to indwelling urinary catheter removal, time to ambulation, and time to hospital discharge). Baseline demographics and outcomes were compared between pre-ERAC and post-ERAC cohorts. Multivariate logistic regression models were used to control for potential confounders. Results: Of 308 patients undergoing CD from October 2019 to September 2020, 196 were enrolled in the pre-ERAC cohort and 112 in the post-ERAC cohort. Patients in the post-ERAC cohort were less likely to require opioids in the postoperative period compared to the pre-ERAC cohort (35.7% vs. 18.4%, p<0.001). In addition, there was a significant reduction in the MME per stay in this cohort [16.8 MME (11.2-33.9) vs. 30 MME (20-49), p<0.001]. In the post-ERAC cohort, there was also a reduction in the number of patients who required prescribed opioids at the time of discharge (86.6 vs. 98%, p<0.001) as well as in the amount of MMEs prescribed [150 MME (112-150) vs. 150 MME (150-225), p<0.001; different shape of distribution]. Patients in the post-ERAC cohort had lower delta pain scores on postoperative days 1 to 4 as well as lower overall delta pain scores [2.2 (1.3-3.7) vs. 3.3 (2.3-4.7), p<0.001]. Conclusion: Our study has illustrated that our ERAC pathways reduced inpatient and outpatient opioid use as well as patient-reported pain scores while improving indicators of postoperative recovery.

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Targeted housestaff intervention reduces opioid use without worsening patient-reported pain scores and improves outcomes among patients with IBD: the “IBD pain ladder”

International Journal of Colorectal Disease ◽

10.1007/s00384-021-03852-7 ◽

2021 ◽

Author(s):

Pavlos Kaimakliotis ◽

Ajit Ramadugu ◽

Jennifer Kang ◽

Timothy McGorisk ◽

Anne Polick ◽

...

Keyword(s):

Opioid Use ◽

Pain Scores ◽

Patient Reported

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Efficacy of a password-protected pill-dispensing device to enhance disposal of unused opioids after cancer surgery.

Journal of Clinical Oncology ◽

10.1200/jco.2020.39.28_suppl.264 ◽

2021 ◽

Vol 39 (28_suppl) ◽

pp. 264-264

Author(s):

Jacob Cogan ◽

Melissa Kate Accordino ◽

Melissa Parsons Beauchemin ◽

Sophie Ulene ◽

Elena B. Elkin ◽

...

Keyword(s):

Pain Control ◽

Cancer Surgery ◽

High Rate ◽

Smartphone App ◽

Opioid Use ◽

Structured Interviews ◽

Health Crisis ◽

Patient Reported ◽

After Cancer ◽

The Impact

264 Background: Opioid misuse is a public health crisis. Initial opioid exposures often occur post-operatively, and 10% of opioid-naïve patients who undergo cancer surgery subsequently become long-term opioid users. It has been shown that 70% of opioids prescribed post-operatively go unused, but only 9% of unused pills are disposed appropriately, which increases the risk of unintended use. We evaluated the impact of an inexpensive, password-protected dispensing device with mail return capacity on retrieval of unused pills after cancer surgery. Methods: Adult patients scheduled for major cancer-related surgery were eligible. Enrolled patients received opioid prescriptions in a password-protected, pill-dispensing device (Addinex) from a specialty pharmacy. The mechanical device links to a smartphone app, which provides passwords on a prescriber-defined schedule. Patients request a password when they are in pain, enter the password into the device and receive a pill if the prescribed time has elapsed. The smartphone app provides clinical guidance based on patient-reported pain levels, and suggests tapering strategies. Patients are instructed to return the device in a DEA-approved mailer when opioid use is no longer required for pain control. Unused pills are destroyed upon receipt. The primary objective was to determine the feasibility of device return, defined as > 50% of patients with device return. We also explored patterns of device use, patient reported outcomes, and device satisfaction via surveys and semi-structured interviews. Results: Between October, 2020 and April, 2021, 13 patients completed the study; 4 patients are currently enrolled. Among the initial 13 patients, 7 underwent abdominal hysterectomy, 4 underwent mastectomy and 2 underwent cutaneous tumor resections. The majority of these patients (n = 10, 77%) returned the device, and more than half (n = 7, 54%) returned the device within 6 weeks of surgery. Only a minority of patients (n = 5, 38%) used the device to obtain opioids; most (n = 8, 62%) used no opioids at home, and all of these patients returned the device and the unused pills. Of 11 patients who participated in semi-structured interviews, most (n = 7, 64%) said they felt safer having opioids in the device instead of a regular pill bottle. Among device users, the majority (n = 4, 80%) reported an overall positive experience. All non-users reported having no opioid requirement for pain control. Conclusions: Our early findings suggest that use of an inexpensive, password-protected, pill-dispensing device to assist with opioid dispensing and return is feasible, with a high rate of device and unused opioid return to the pharmacy. This strategy may be effective for reducing opioid diversion. Analyses and recruitment are ongoing to evaluate the benefits of reducing post-operative opioid consumption.

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Preoperative Fascia Iliaca Block Does Not Improve Analgesia after Arthroscopic Hip Surgery, but Causes Quadriceps Muscles Weakness

Anesthesiology ◽

10.1097/aln.0000000000002321 ◽

2018 ◽

Vol 129 (3) ◽

pp. 536-543 ◽

Cited By ~ 21

Author(s):

Matthias Behrends ◽

Edward N. Yap ◽

Alan L. Zhang ◽

Kerstin Kolodzie ◽

Sakura Kinjo ◽

...

Keyword(s):

Placebo Group ◽

Hip Arthroscopy ◽

Pain Control ◽

Recovery Room ◽

Study Endpoint ◽

Block Group ◽

Opioid Use ◽

Quadriceps Weakness ◽

Pain Scores ◽

Fascia Iliaca Block

Abstract What We Already Know about This Topic What This Article Tells Us That Is New Background Ambulatory hip arthroscopy is associated with postoperative pain routinely requiring opioid analgesia. The potential role of peripheral nerve blocks for pain control after hip arthroscopy is controversial. This trial investigated whether a preoperative fascia iliaca block improves postoperative analgesia. Methods In a prospective, double-blinded trial, 80 patients scheduled for hip arthroscopy were randomized to receive a preoperative fascia iliaca block with 40 ml ropivacaine 0.2% or saline. Patients also received an intraarticular injection of 10-ml ropivacaine 0.2% at procedure end. Primary study endpoint was highest pain score reported in the recovery room; other study endpoints were pain scores and opioid use 24 h after surgery. Additionally, quadriceps strength was measured to identify leg weakness. Results The analysis included 78 patients. Highest pain scores in the recovery room were similar in the block group (6 ± 2) versus placebo group (7 ± 2), difference: −0.2 (95% CI, −1.1 to 0.7), as was opioid use (intravenous morphine equivalent dose: 15 ± 7mg [block] vs. 16 ± 9 mg [placebo]). Once discharged home, patients experienced similar pain and opioid use (13 ± 7 mg [block] vs. 12 ± 8 mg [placebo]) in the 24 h after surgery. The fascia iliaca block resulted in noticeable quadriceps weakness. There were four postoperative falls in the block group versus one fall in the placebo group. Conclusions Preoperative fascia iliaca blockade in addition to intraarticular local anesthetic injection did not improve pain control after hip arthroscopy but did result in quadriceps weakness, which may contribute to an increased fall risk. Routine use of this block cannot be recommended in this patient population.

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ESRA19-0631 Efficacy of pain control following scheduled cesarean delivery under intrathecal anaesthesia, and the need for opioid use in the first 24 hours

10.1136/rapm-2019-esraabs2019.499 ◽

2019 ◽

Author(s):

V Singh ◽

S Lal ◽

J Thomas ◽

N Narayanan ◽

A Malik

Keyword(s):

Cesarean Delivery ◽

Pain Control ◽

Opioid Use

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Towards Opioid-Free Elective Spine Surgery: A Prospective Cohort Study

Neurosurgery ◽

10.1093/neuros/nyz310_114 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Ahilan Sivaganesan ◽

Amanda Wright ◽

Regis W Haid ◽

Praveen V Mummaneni ◽

Richard Berkman

Keyword(s):

Cohort Study ◽

Prospective Cohort Study ◽

Spine Surgery ◽

Prospective Cohort ◽

Multivariate Regression ◽

Opioid Use ◽

Pain Scores ◽

Patient Reported ◽

Average Pain ◽

Student’S T

Abstract INTRODUCTION The opioid crisis is a national emergency. We conducted a prospective cohort study to determine whether elective spine surgery can be performed without any opioids whatsoever. METHODS Every consecutive elective spine surgery performed by author R.A.B. between January 1st and December 31st of 2018 was included. For cohort A, between January and April 15th, opioids were minimized but PRN doses were given. For cohort B, between April 15th and December, the goal was to eliminate opioids altogether. Pain scores were collected at discharge, 1 wk, and 1-mo follow-up. Patient-reported outcomes (PRO) were collected at baseline and at 3 mo for lumbar procedures. Emergency room visits and readmissions were tracked. Student's t-tests were used to compare pain scores and PROs, and multivariate regression analyses were performed to understand drivers of opioid use. RESULTS A total of 158 patients were included. In cohort A, 37.9% of patients took no opioids between PACU and 1 mo. Average pain scores were 5.2 in PACU and 2.5 at 1 mo. In cohort B, 86.7% took no opioids after PACU. Average pain scores were 4.2 in PACU and 2.5 at 1 mo. Both cohorts had equivalent improvements in PROs. Multivariate regression revealed that, adjusting for case mix differences, cohort B had lower odds of opioid use after PACU (P < .0001). Moreover, preoperative opioid use is a driver of postoperative opioid use (P = .02), whereas procedure type/invasiveness is not. CONCLUSION We have shown that opioid-free spine surgery, including lumbar fusions, is feasible and effective. In all 87% of patients in our opioid-elimination cohort took no opioids from PACU until 1 mo after surgery, and 94% were taking none at the 1-mo visit. Pain scores and PROs were favorable. We have also shown that preoperative opioids are a driver of postoperative opioid use, however procedural invasiveness is not.

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