The missing step in ERAS: eliminating routine opioid prescription after thoracic surgery

Enhanced recovery after surgery (ERAS) protocols have significantly improved patients’ surgical experience in the last few decades, especially after the standardization of perioperative care and the focus on opioid-sparing practices. Despite these efforts, the opioid crisis remains a public health emergency, and the tempered optimism of its decline was short-lived, with a provisional increase in overdose deaths reported by the Centers for Disease Control and Prevention in January 2025 (1). Hence, enhanced recovery protocols emphasizing opioid consumption merit highlighting, particularly in thoracic surgery, in which the patient population experiences the highest number of new opioid dependences after surgery (2,3).

Pratt et al. analyzed an institutional database linked to a regional prescription drug monitoring program to determine the impact of the ERAS program on opioid use, surgical outcomes, and, more importantly, on new persistent opioid use after surgery. Overall, their study showed that the ERAS program was associated with decreased total inpatient morphine milliequivalent (MME), total intensive care unit and hospital length of stay, chest tube duration, and air leak >5 days but had an increase in the number of patients being discharged home on opioids from 78% to 90% in the opioid naïve group (4). In the non-naïve opioid group, there was a decrease in the total and average amount of inpatient MME and the amount of MME at discharge; however, their study showed that their ERAS program was not associated with a change in the length of stay, chest tube duration, or air leak >5 days or the number of patients being discharged home on opioids from 87.5% to 79.1%. This is similar to the findings of our initial efforts to implement the ERAS program at our institution. When we first implemented the ERAS program, we found that 98% of the patients went home with opioids, but the majority of them went home with Schedule IV opioid medications compared to Schedule II opioid medications (5). After implementing the ERAS program, Pratt et al. reported that 10.9% of patients in the naïve opioid group had new persistent opioid use. One of the main factors associated with persistent opioid use is discharge home on opioids. All patients with persistent opioid use were prescribed opioids at the time of discharge whether they really needed it or not.

Opioids are addictive medications; thus, being prescribed opioids after surgery increases the probability of long-term opioid use (6). In our program, we did not observe a reduction in the discharge opioid use at home until we stopped prescribing opioids as standard discharge medications (7). Our opioid prescription rate decreased from 76.7% to 17.4%. At four weeks follow up, none of the patients who went home without opioids required opioid medication. Our program was successful because of the intensive education of the patient, physicians, and nurses about changing the concept of pain-free after surgery to pain being manageable and the importance of using multimodal non-opioid medication to achieve pain control.

We implemented this by first setting the pain expectation with patients and explaining to them what to anticipate and how best to manage the pain. We explained to the patients that they would experience pain for approximately 4–6 weeks after robot-assisted thoracoscopic lung surgery and that the goal of pain management was to ensure that the pain was manageable. We explained that we would mainly use non-opioid medications. During the operation, the patients received an intraoperative rib block with liposomal bupivacaine directly next to the intercostal nerve. We have partnered with our anesthesiologists to provide opioid-free anesthesia, which has been shown to decrease opioid use after surgery (8). In addition, we remove the chest tube on the same day or the next day after surgery, which minimizes pain. Patients are started on around the clock acetaminophen, gabapentin, methocarbamol and Lidoderm patch and when appropriate nonsteroidal anti-inflammatory drugs after surgery and they go home on around the clock regimen of at minimum of acetaminophen and gabapentin for seven days with as needed other medications. This has helped us avoid prescribing opioids for home. Similarly, low rates of opioid prescription (25%) after thoracic surgery have been achieved in other mature ERAS programs (9).

Pratt et al.’s important message is that when patients go home on opioids after thoracic surgery, there is a higher chance that patients will be on persistent opioids. Every effort should be made to optimize multimodal non-opioid medication and set patient, provider, and nurse expectations to avoid discharging patients who are on opioids after surgery.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Current Challenges in Thoracic Surgery. The article has undergone external peer review.

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-44/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-44/coif). M.P.K. received honoraria from Intuitive Surgical for teaching surgeons how to perform robotic thoracic surgery. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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