Lower surgical opioid dosage leads to less long-term use, Kaiser Permanente research finds

But if patients already use opioids before surgery, they are more likely to continue later

Oakland, Calif. — Surgical patients given less opioids and more alternative methods of pain control were less likely to continue using opioids 6 months to a year later, an analysis by Kaiser Permanente Northern California researchers finds.

The research letter, published in Annals of Surgery June 20, compared long-term opioid use by groups of surgery patients during the periods before and after an Enhanced Recovery After Surgery (ERAS) program was put in place, and found a significant difference. The ERAS program is used in all of Kaiser Permanente’s 21 Northern California hospitals and offers improved pain control (including reduced opioid doses), more robust pre-surgery nutrition, a focus on getting patients moving soon after surgery, and better patient engagement in their recovery.

“A standardized and targeted approach to pain management in the ERAS program could have long-term benefits,” said Vincent Liu, MD, MS, lead author and an investigator with the Kaiser Permanente Northern California Division of Research.

A study by Kaiser Permanente researchers published in JAMA Surgery in 2017 found the program was associated with reduced length of stay in the hospital and fewer complications.

Liu and colleagues explored that data to determine how these surgery patients fared with opioid use 6 months to a year later. Patients introduced to an opioid during surgery can face an increased risk of developing an opioid use disorder.

They compared groups of patients who had surgery before ERAS with those who were treated after it started and found a dramatic difference: the rate of long-term opioids use was more than 30% before ERAS implementation and under 10% a year after.

A key exception to the improvement was found among patients who had already been taking opioids before their surgery. In those cases, the patients were much more likely to continue long-term use at 6 months or a year.

“Patients on opioids before surgery remain a target and opportunity to understand how we can try to make their recovery better,” Dr. Liu said.

The research suggests ERAS methods can have long-term benefits, said senior author Stephen M. Parodi, MD, associate executive director of The Permanente Medical Group.

“We know careful attention to the welfare of surgical patients can enhance their recovery and facilitate a swifter discharge out of the hospital,” Dr. Parodi said.  “This study suggests additional ERAS benefits by decreasing long-term painkiller use in patients not receiving pre-operative opioids and, as a result, reducing the risk of developing a post-operative opioid use disorder.”

The study compared the hip and colorectal surgery patients who were part of the ERAS program with control groups of abdominal surgery and orthopedic surgery patients whose care did not follow the protocol but who received usual hospital care. Interestingly, this group also experienced similar rates of reduction in long-term use of opioids.

“We think this finding may represent a ‘halo effect,’ where ERAS principles were naturally transferred to additional types of surgery,” said Derrick Lee, MD, an anesthesiologist and Kaiser Permanente Northern California ERAS clinical lead. “The ERAS program also promoted greater awareness of opioid therapy risk and helped introduce an opioid-sparing pain management strategy known as multimodal analgesia.”

Dr. Liu noted some limitations of the research: it did not look at other factors in the patients’ year after surgery such as additional surgeries or uncontrolled pain. Also, he said, the results could have been influenced by a national effort among physicians to reduce their opioid prescribing over the past several years.

The research was funded by The Permanente Medical Group and the National Institute of General Medical Sciences. Additional authors included Andy L. Avins, MD, MPH, Vivian Reyes, MD, Abigail Eaton, PhD, and Cynthia I. Campbell, PhD, MPH, from the Kaiser Permanente Division of Research; and Shirley S. Paulson, DNP, from Kaiser Permanente Northern California.

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