Opioid-Sparing and Zero-Opioid Protocols Decrease Consumption Following Surgery

A prospective cohort study found that preoperative education and a multimodal analgesia intervention can result in no prescribed opioids following outpatient elective general surgery without decreasing patient satisfaction or increasing pain scores. These findings were published in the Journal of Surgical Research.

Opioid-naive patients (N=129) who underwent elective outpatient inguinal hernia repair or cholecystectomy at Thomas Jefferson University between 2019 and 2021 were recruited for this study (ClinicalTrials.gov Identifier: NCT05327777). Patients treated when the normal institutional protocols were in place between November 2019 and February 2020 were used as the control cohort (n=58) and compared with patients treated during the opioid-sparing intervention between March 2020 and October 2020 (n=42) and the zero-opioid intervention between November 2020 and July 2021 (n=29). Study outcomes included morphine milligram equivalents (MME) opioid use and patient-reported pain scores and satisfaction on a 10-point scale.

The opioid-sparing intervention consisted of education tailored to the specific procedure and the Safe and Effective Pain Control After Surgery patient tool; preoperative multimodal analgesia with ibuprofen 800 mg, acetaminophen 1000 mg, and pregabalin 75 mg; goal-directed fluid management; and postoperative opioid dispensation only with visual analog scores (VAS) greater than 6. At discharge, patients were advised to limit their opioid use at home. During the zero-opioid protocol, no opioids were prescribed at discharge.

The control, opioid-sparing, and zero-opioid cohorts consisted of 32.8%, 23.8%, and 6.9% women (P =.029); mean age in each cohort was 52.4, 55.3, and 58.6 years; 81.0%, 73.8%, and 75.9% of participants were White; and 5.2%, 11.9%, and 13.8% of participants had a history of substance use, respectively.

Compared with patients in the control group (55.2%), more patients in the zero-opioid (86.2%) and opioid-sparing (73.8%) cohorts underwent inguinal hernia repair (P =.009). More patients in the zero-opioid and opioid-sparing groups underwent open surgery (37.9% vs 35.7% vs 18.2%; P =.017) and had a longer postprocedure length of stay (median, 5.1 vs 4.7 vs 2.7 h; P =.0001) compared with patients in the control group, respectively. Participants in the control and zero-opioid groups received a median intraoperative MME of 480 mg compared with 420 mg for participants in the opioid-sparing group (P =.0001).

In the postanesthesia care unit, no significant group differences in MME were observed.

After discharge, opioid use decreased significantly from a median MME of 46 (interquartile range [IQR], 37.5-75.0) mg observed among participants in the control group to 15 (IQR, 11.0-22.5) mg among participants in the opioid-sparing group and an average of 0±0 mg among participants  in the zero-opioid cohort (P =.0001). No group differences were observed for pain scores (median, 3 vs 2 vs 4; P =.08) or patient satisfaction (median, 10 vs 10 vs 10; P =.8302) among patients in the control, opioid-sparing, and zero-opioid cohorts, respectively.

At 30 days, no patient in the zero-opioid group contacted a physician due to pain compared with 17.2% of patients in the control group and 23.8% of patients in the opioid-sparing cohort (P =.022).

A limitation of this study is that its findings may not be generalizable to opioid-exposed patients.

This study found that opioid-sparing and zero-opioid policies significantly reduced opioid use without affecting pain or patient satisfaction. The study authors conclude, “We hope our protocol can serve as a model for opioid reduction in other outpatient elective surgeries and spur discussion on strategies to mitigate opioid use in more urgent/emergent or extensive procedures in an effort to reduce the contribution of provider-prescribed opiates to the current epidemic.”