Enhanced Recovery After Surgery Protocol for Opioid Use Reduction in Ambulatory Thyroid and Parathyroid Surgery

Introduction: The risk of long-term opioid use (90–180 days) in previously opioid-naive patients ranges from 5.9% to 6.5%.1,2 Recent studies conducted investigating whether implementing an enhanced recovery after surgery (ERAS) protocol in endocrine surgery can help surgeons prescribe less opioid pain medication postoperatively suggest that such protocols can be effective.3 Nearly 60% of endocrine surgeons self-report prescribing opioids routinely postoperatively,4 and our protocol can be implemented in whole or in part to help surgeons try a new method to manage perioperative pain.5 Materials and Methods: We compared patients from before implementation of the ERAS protocol with patients who were enrolled in a prospective study of patients who underwent the new protocol. Pre-ERAS group: February 2016–January 2017. Post-ERAS group: September 2018–February 2019. Surgical and anesthesia team members involved were emailed on a daily basis before their cases to remind them of the protocol. Exclusion criteria were lateral neck dissection, substernal or retroclavicular dissection, sternotomy, or clavicular osteotomy. Data were collected using electronic medical records, the statewide prescription drug monitoring program, and analyzed using REDCap at University of Arkansas for Medical Sciences (UAMS). Results: In total, 332 patients were included, 199 of whom had surgery before ERAS protocol implementation and 133 of whom participated in the ERAS protocol. Post-ERAS protocol participants were prescribed an average of 83 morphine milligram equivalents (MME) per prescription, which was significantly reduced compared with patients before the protocol who were prescribed an average of 199 MME per prescription (p < 0.001). Among the preprotocol patients, 82.9% were prescribed opioids postsurgery with 90% of prescriptions filled. Among postprotocol patients, 75.9% were prescribed opioids, with 84% of prescriptions filled. Postoperative pain scores were evaluated on a scale of 0–10. Mean pain scores were 4.38, 3.77, and 2.77 on postoperative days 1, 2, and 3, respectively. As a measure of adherence to the ERAS protocol, 85% of patients received acetaminophen and superficial cervical plexus blocks preoperatively. Conclusions: Implementation of an ERAS protocol with interdisciplinary multimodal pain management significantly decreased the average MME prescribed to patients undergoing ambulatory thyroid and parathyroid surgery with adequate control of postoperative pain. Our goal of <50 MME per prescription was not attained during the time course of this study; however, reduction <90 MME per prescription was achieved, which is not associated with a greater risk of long-term opioid use. No competing financial interests exist. Runtime of video: 3 mins 38 secs