Enhanced recovery after surgery protocol and postoperative opioid prescribing for cesarean delivery: an interrupted time series analysis

E M Langnas,R Rodriguez-Monguio,M W Harbell,A Lin,R Croci,Z A Matthay,C L Chen

doi:10.1186/s13741-021-00209-0

Abstract

IntroductionEnhanced recovery after surgery (ERAS) pathways have emerged as a promising strategy to reduce postoperative opioid use and decrease the risk of developing new persistent opioid use in surgical patients. However, the association between ERAS implementation and discharge opioid prescribing practices is unclear.Study designWe conducted a retrospective observational quasi-experimental study of opioid-naïve patients aged 18+ undergoing cesarean delivery between February 2015 and December 2019 at a large academic center. An interrupted time series analysis (ITSA) was used to model the changes in pain medication prescribing associated with the implementation of ERAS to account for pre-existing temporal trends.ResultsAmong the 1473 patients (out of 2249 total) who underwent cesarean delivery after ERAS implementation, 80.72% received a discharge opioid prescription vs. 95.36% at baseline. Pre-ERAS daily oral morphine equivalents (OME) on the discharge prescription decreased by 0.48 OME each month (p<0.01). There was a level shift of 35 more OME prescribed (p<0.01), followed by a monthly decrease of 1.4 OMEs per month after ERAS implementation (p<0.01). Among those who received a prescription, 61.35% received a total daily dose greater than 90 OME compared to 11.35% pre-implementation (p<0.01), while prescriptions with a total daily dose less than 50 OME decreased from 79.86 to 25.85% after ERAS implementation(p<0.01).ConclusionAlthough ERAS implementation reduced the overall proportion of patients receiving a discharge opioid prescription after cesarean delivery, for the subset of patients receiving an opioid prescription, ERAS implementation may have inadvertently increased the prescribing of daily doses greater than 90 OME. This finding highlights the importance of early and continued evaluation after new policies are implemented.

Highlights

Enhanced recovery after surgery (ERAS) pathways have emerged as a promising strategy to reduce postoperative opioid use and decrease the risk of developing new persistent opioid use in surgical patients
Pre-ERAS daily oral morphine equivalents (OME) on the discharge prescription decreased by 0.48 OME each month (p
There was a level shift of 35 more OME prescribed (p

Summary

Introduction

Enhanced recovery after surgery (ERAS) pathways have emerged as a promising strategy to reduce postoperative opioid use and decrease the risk of developing new persistent opioid use in surgical patients. In the USA, opioids are often over-prescribed to patients after surgical procedures, which results in excess and unused opioids (Berterame et al 2016; Baker et al 2016; Wunsch et al 2016; Bicket et al 2017; Brummett et al 2019; Howard et al 2019). Excess opioids prescribed at discharge are a potential source for overdose, misuse, diversion, and new persistent opioid use among surgical patients (Berterame et al 2016; Dowell et al 2013; Brummett et al 2017). Almost all women undergoing cesarean delivery are exposed to opioids during their hospitalization, and 85% of women fill their first opioid prescription upon hospital discharge (Bateman et al 2017). 83% of women undergoing cesarean delivery reported having leftover prescription opioids, which may increase the risk of misuse or diversion (Bartels et al 2016)

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