Surgical Opioid-Avoidance Protocol Improves Opioid Outcomes Without Affecting Pain

Surgical opioid-avoidance protocol is as effective as the nonprotocol comparison (no opioid restriction) for managing postoperative pain.

A surgical opioid-avoidance protocol (SOAP) is associated with decreased postoperative opioid use and prescription of opioids at discharge but does not affect postoperative pain scores compared with a pre-SOAP intervention. These findings were published in Regional Anesthesia & Pain Medicine.

The SOAP intervention was formulated after examining patients undergoing different operations and used an aggressive opioid-avoidance order set with patient and staff education.

This prospective cohort study was designed to evaluate the outcomes of SOAP among opioid-naive patients undergoing various surgical procedures. Patients (N=841) scheduled for operation at the University of Illinois Chicago, College of Medicine were evaluated for postoperative pain scores, opioid use, and opioids distributed at discharge. The patients were stratified by whether they underwent operation before the SOAP intervention was implemented (2018; n=382) or after (2019; n=449).

This protocol could serve as an effective tool to decrease postoperative exposure to opioids, thereby addressing a gateway to opioid misuse and community diversion.

The pre-SOAP and SOAP groups comprised patients with a mean [SD] age of 51.3[15.9] and 50.65[15.86] years; 60.0% and 61.5% were women; 41.9% and 45.0% were Black; 64.9% and 70.8% underwent general, minimally invasive, or robotic operation; and 34.6% and 34.5% had open or conversion to open surgical procedures, respectively.

Maximum daily pain scores did not differ significantly between groups from the day of operation until day 5. Adjusting for demographic and clinical characteristics did not affect these outcomes, and SOAP was determined to be noninferior to no SOAP intervention.
Significant predictors for maximum pain scores included age (estimate, -0.04; P <.01) and female gender (estimate, 0.39; P =.04), but not SOAP (estimate, -0.24; P =.17).

The SOAP vs pre-SOAP groups were associated with significant decreases in the total morphine milliequivalent (MME) dose received (mean, 0.67 vs 8.17 mg; P <.01). Fewer patients in the SOAP vs pre-SOAP group received intravenous opioids (21.2% vs 47.0%; P <.01), fewer received opioids at discharge (43.9% vs 70.2%; P <.01), and they were given a lower MME dose at discharge (median, 0 vs 86.4 mg; P <.01), respectively. However, more patients treated during the SOAP intervention received tramadol (30.3%) than during the pre-SOAP intervention (15.2%; P <.01).

The limitations of this study included the single center, nonrandomized design and the potential for selection and observational biases.

These data indicated that a SOAP intervention had significant effects on opioid consumption and prescribing patterns but no significant effects on pain outcomes. The study authors concluded, “This protocol could serve as an effective tool to decrease postoperative exposure to opioids, thereby addressing a gateway to opioid misuse and community diversion.”


Votta-Velis G, Daviglus ML, Borgeat A, et al. Surgical opioid-avoidance protocol: a postoperative pharmacological multimodal analgesic intervention in diverse patient populations. Reg Anesth Pain Med. Published online April 6, 2023. doi:10.1136/rapm-2022-103864