Published On July 20, 2017
SURGERY SHOULD IMPROVE THE LIFE OF A PATIENT. But a widely cited Stanford study from last year discovered that after 11 of the most common operations, patients had an elevated risk of becoming addicted to their painkillers.
When patients leave the hospital, as many as 40% of the opioid medications they’re prescribed aren’t used immediately, according to several studies. Often the pills get used later or by someone else, helping fuel a national epidemic of misuse that causes more than 60 deaths each day.
While many efforts focus on helping those who are already addicted, some hospitals are looking at how to scale down—or eliminate entirely—the use of opioids after an operation. A new generation of surgical procedures can minimize the length of incisions and otherwise be less invasive, allowing patients to recover more quickly and with less pain. At the hospital, the patient can be treated with local anesthetics and a combination of non-opioid painkillers, such as acetaminophen and aspirin, and be coached on how to manage pain at home without opioids.
Combine these ideas and others like them, and you have guidelines known as enhanced recovery after surgery, or ERAS. Developed in Europe and slowly making its way to U.S. hospitals, this approach aims to improve the surgical experience in many ways, not least of which is arming the patient with better tools for managing their pain.
“With ERAS, patients do much better and have less pain than after traditional surgeries, and there are fewer issues with addictive medications,” says Clifford Ko, a colorectal surgeon and director of the Division of Research and Optimal Patient Care at the American College of Surgeons. The ACS is launching a program to bring ERAS programs to 750 hospitals, with the first cohort beginning this summer.
ERAS takes aim at some sacred cows. A patient in ERAS gets to eat a normal meal the night before surgery and drink a carbohydrate-rich drink as late as two hours before the operation, instead of having to fast. Fasting can drive up insulin resistance—a metabolic process that may disrupt post-operative healing. And while these relaxed guidelines aren’t new—the American Society of Anesthesiologists suggested them more than 18 years ago—many anesthesiologists still adhere to a dogma of overnight fasting.
“Hospitals are like supertankers,” says Liliana Bordeianou, chief of the colorectal surgery center at Massachusetts General Hospital, who developed and implemented the ERAS protocol at that hospital. “It’s really difficult to change course, and everybody finds excuses not to.”
ERAS has shown remarkable results: Patients spend 30% to 50% fewer days in the hospital after an operation, and wound infections and other complications have been reduced by as much as half. At MGH, the typical colorectal ERAS patient leaves the hospital in two to three days, says Bordeianou, compared to seven days after surgery without this protocol. And patients typically require a prescription for only a few days’ worth of painkillers, rather than an initial prescription for 60 opioid tablets that could often be refilled.
“Now my patients go home with 15 tablets,” says Bordeianou. “Many people don’t even need those because we teach them not to take a pill until they’ve tried reducing the pain with a warm compress. We also tell them to take more acetaminophen or ibuprofen around the clock to stop pain before it starts.”
Tonia Young-Fadok, professor of surgery at the Mayo Clinic and president of ERAS USA, notes that the guidelines had been developed in Europe before today’s opioid epidemic. The initial focus had been on a speedier recovery and minimizing the use of opioids because they slow down gut function. “But lowering the risk of opioid abuse is an unexpected benefit,” she says.
With ERAS, patients are also told they should plan to be walking again quickly—within hours of surgery, if possible. The sooner patients get moving again, Bordeianou says, the more likely they are to have a complication-free recovery.
“People think, ‘Oh my god, she just opened me up. Is it safe to get up?’” she says. “Not only is it safe, it actually tells the body, ‘Nothing happened here, stop sending those signals of pain, stop shutting down the intestine, it’s not necessary.’”
ERAS also reduces the cost of surgery—by an average of $7,103 for colorectal procedures, according to a study by Young-Fadok. And getting patients out of the hospital more quickly frees up beds for other patients who may need them.
“Because these protocols are evidence based, most providers will readily accept that they’re basically the right thing to do,” says Ko.
But adoption is bound to take time. “ERAS changes what people have done for many years,” says Young-Fadok. “We’ve gone from being generous with narcotic pain meds to saying, ‘Hang on, we now have better ways of managing your pain. If you haven’t needed large doses of narcotics while you were in the hospital, you shouldn’t need them when you go home.’” That’s a culture shift for both hospital and patient.
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