Enhanced recovery in liver surgery decreases postoperative outpatient use of opioids.

Enhanced recovery in liver surgery decreases postoperative outpatient use of opioids.

Lillemoe HA et al (2019) Enhanced recovery in liver surgery decreases postoperative outpatient use of opioids. Surgery. May 15. pii: S0039-6060(19)30074-1. 

What is already known?

The opioid epidemic, as it has come to be known, is a worsening global crisis. The problem appears to largely stem from high rates of opioid prescriptions and patients stockpiling and passing-on prescribed opioids to other users both of which conspire towards addiction. One of the main principles of ERAS is that if multi-modal analgesia equating to opioid-sparing. Many studies have shown a reduction in the use of opioids in the immediate perioperative period in patients enrolled on an ERAS programme. There is currently no evidence that this has translated into a reduction in opioid use post-hospital discharge. There is, in fact, a suggestion that the opposite may be true in view of patients on ERAS programmes leaving hospital earlier with higher analgesia requirements at the point of discharge.

What this paper adds:

The authors believe this to be the first paper looking at post-discharge prescriptions and use of opioids at the first follow-up appointment for patients having undergone major oncological surgery – namely liver resection surgery. The paper demonstrates a startling reduction in prescriptions for “traditional” opioids in patients following an ERAS pathway (26% versus 79% in patients following standard care). By the first follow-up appointment significantly fewer patients in the ERAS group were taking “traditional” opioids. Both groups, however, reported similar pain scores at this stage of their treatment. The authors point out that the dramatic reduction in opioid prescriptions results in far fewer opioid pills being potentially available in the community to pass-on to other users. ERAS patients were more likely to be prescribed tramadol (a non-“traditional” opioid with comparatively little addictive potential). This, in turn, meant they were substantially less likely to require more addictive opioids, if any opioids at all, by first follow-up. This paper demonstrates the importance of continuing the principles of ERAS beyond the immediate post-operative period and the potential public health improvements this can lead to.

Ben Morrison, Guildford