Impact of Enhanced Recovery After Surgery and Opioid-Free Anesthesia on Opioid Prescriptions at Discharge From the Hospital: A Historical-Prospective Study.
Impact of Enhanced Recovery After Surgery and Opioid-Free Anesthesia on Opioid Prescriptions at Discharge From the Hospital: A Historical-Prospective Study.
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DOI：
10.1213/ane.0000000000002510
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发表时间：
2017-11
影响因子：
5.7
通讯作者：
Cannesson M
中科院分区：
文献类型：
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作者：
Brandal D;Keller MS;Lee C;Grogan T;Fujimoto Y;Gricourt Y;Yamada T;Rahman S;Hofer I;Kazanjian K;Sack J;Mahajan A;Lin A;Cannesson M
美国正处于阿片类药物流行之中，阿片类药物使用障碍通常始于急性疼痛的处方。围手术期是预防慢性阿片类药物使用的重要机会，最近出现了实施术后恢复增强（ERAS）方案的范式转变，该方案促进了无阿片类药物和多模式镇痛。本研究的目的是评估ERAS干预结直肠手术对出院阿片类药物处方实践的影响。我们对接受结直肠手术的患者实施的ERAS方案进行了一项历史-前瞻性质量改进研究，重点关注该途径的无阿片类药物和多模式镇痛成分。我们比较了实施前1年（2015年6月15日至2016年6月14日）和实施后1年（2016年6月15日至2017年6月14日）接受结直肠手术的患者。在ERAS干预之前，出院时阿片类药物没有显著增加（每月1%; 95%置信区间[CI]，-1%至3%; P = .199）。在ERAS干预后，阿片类药物处方并没有显著降低（13%; 95% CI，-30%至3%; P = .110）。干预后，出院时阿片类药物处方率与前期相比没有显著下降1%（95% CI，-3%至1%）（P = .399）。亚组分析显示，在出院疼痛评分低、术前未使用阿片类药物和出院前吗啡毫克当量消耗量低的患者中，出院阿片类药物处方率为72%（95% CI，61%-83%）。这项研究是第一个报告在ERAS环境中出院阿片类药物处方实践的研究。尽管ERAS干预结直肠手术导致无阿片类药物麻醉和多模式镇痛的增加，但我们没有观察到对出院阿片类药物处方实践的影响。大多数患者出院时使用阿片类药物处方，包括出院前疼痛评分较低、术前未使用阿片类药物和吗啡毫克当量消耗量较低的患者。在ERAS通路促进多模式镇痛的背景下的这一观察结果表明，我们的研究结果很可能也在非ERAS环境中观察到，并提供了一个机会来修改术后出院时的阿片类药物处方实践。对于影响阿片类药物流行的无阿片类药物麻醉和多模式镇痛，应根据住院疼痛评分和阿片类药物使用以及入院前疼痛史收集的信息修改处方阿片类药物的剂量和数量。
The United States is in the midst of an opioid epidemic, and opioid use disorder often begins with a prescription for acute pain. The perioperative period represents an important opportunity to prevent chronic opioid use, and recently there has been a paradigm shift toward implementation of enhanced recovery after surgery (ERAS) protocols that promote opioid-free and multimodal analgesia. The objective of this study was to assess the impact of an ERAS intervention for colorectal surgery on discharge opioid prescribing practices. We conducted a historical-prospective quality improvement study of an ERAS protocol implemented for patients undergoing colorectal surgery with a focus on the opioid-free and multimodal analgesia components of the pathway. We compared patients undergoing colorectal surgery 1 year before implementation (June 15, 2015, to June 14, 2016) and 1 year after implementation (June 15, 2016, to June 14, 2017). Before the ERAS intervention, opioids at discharge were not significantly increasing (1% per month; 95% confidence interval [CI], −1% to 3%; P = .199). Immediately after the ERAS intervention, opioid prescriptions were not significantly lower (13%; 95% CI, −30% to 3%; P = .110). After the intervention, the rate of opioid prescriptions at discharge did not decrease significantly 1% (95% CI, −3% to 1%) compared to the pre-period rate (P = .399). Subgroup analysis showed that in patients with a combination of low discharge pain scores, no preoperative opioid use, and low morphine milligram equivalents consumption before discharge, the rate of discharge opioid prescription was 72% (95% CI, 61%–83%). This study is the first to report discharge opioid prescribing practices in an ERAS setting. Although an ERAS intervention for colorectal surgery led to an increase in opioid free anesthesia and multimodal analgesia, we did not observe an impact on discharge opioid prescribing practices. The majority of patients were discharged with an opioid prescription, including those with a combination of low discharge pain scores, no preoperative opioid use, and low morphine milligram equivalents consumption before discharge. This observation in the setting of an ERAS pathway that promotes multimodal analgesia suggests that our findings are very likely to also be observed in non-ERAS settings and offers an opportunity to modify opioid prescribing practices on discharge after surgery. For opioid-free anesthesia and multimodal analgesia to influence the opioid epidemic, the dose and quantity of the opioids prescribed should be modified based on the information gathered by in-hospital pain scores and opioid use as well as pain history before admission.