Unless you live in a bubble, you know that the US is in the throes of an opioid crisis.
Even though doctors have begun to recognize that opioid use after surgery may play a part in the opioid crisis, more than two million Americans still begin to use and abuse opioids following surgery every year.
Now: Many medical centers have adopted a program known as Enhanced Recovery After Surgery (ERAS). ERAS involves a range of measures to provide a better surgery experience for the patient, resulting in shorter hospitals stays, a reduction in complications and readmissions, and greater patient satisfaction. It also is curbing or eliminating opioid use for surgical procedures. Hospitals using an ERAS protocol are seeing opioid use drastically decline.
The Basics of ERAS
Although the specific ERAS plan differs depending on the type of surgical procedure and the individual patient’s needs, there are some basic principles. Five key steps of ERAS…
If your surgery is not an emergency, your pain-management plan should start before your procedure. For example, before surgery, you will talk to your surgeon and also get a pre-op anesthesia consultation with the anesthesiologist. At this time, your medication needs will be assessed. Knowing what to expect—and working with your team on a pain-management plan—reduces a lot of the anxiety and fear that contribute to pain after surgery.
Before surgery, you’ll likely be asked to stop smoking and drinking alcohol. Tobacco and alcohol use generally does not affect the type of drugs that are administered during surgery, but eliminating both may reduce complications from anesthesia. A few weeks before, you also may be started on an exercise plan (such as daily walking) and/or a healthful diet to prepare your body for the stress of surgery.
Several days before surgery, you may be started on a nonopioid pain medication, such as over-the-counter acetaminophen (Tylenol), a nonsteroidal anti-inflammatory such as celecoxib (Celebrex) or the nerve-pain drug gabapentin (Gralise). This allows the medication to saturate your tissues before surgery and reduces the pain and inflammation reaction during surgery.
Previously, it was common to have nothing to eat or drink after midnight the day before surgery. This was done to prevent any potential risk for aspiration (unintended inhalation of liquid or solid material into the trachea and lungs). An ERAS protocol recognizes that this level of fasting is not necessary. It can cause your body to use up valuable proteins, fats and nutrients that it needs to undergo surgery.
You may be able to have a light diet of a few crackers up to six hours before surgery and drink clear liquids, such as water or apple juice, up to two hours prior to surgery. In addition, you may be instructed to drink a high-carbohydrate drink the day before surgery and another three to four hours before surgery.
A lot can be done during surgery to reduce your pain afterward. Your anesthesiologist may use nonopioid pain medication, such as acetaminophen, celecoxib or gabapentin, just prior to surgery and give you medications to prevent nausea and vomiting when you wake up.
You also may get a nerve block just before the procedure begins to reduce pain when you wake up. The anesthesiologist or surgeon will give the nerve block at the beginning or after the surgery, and its effects can last from hours to a few days.Your anesthesiologist will constantly check your fluid levels, blood glucose and body temperature. Preventing cold stress during surgery reduces the surgical stress.
An ERAS plan kicks into high gear following surgery. It typically includes the following promptly after surgery…
- Mobilization.This can mean sitting in a chair instead of lying in bed and getting up to walk as soon as you can, even if you use a walker. If you can walk, you will be encouraged to go as far as comfortably possible at least twice on the first day after surgery.
- Nutrition. Depending on your surgery, you may be given clear fluids to drink within two hours after surgery. If you can’t drink, you may get fluids through an IV.Many patients can have a full diet the day after surgery.
- Removal of tubes and drains. If you have IV tubes, a Foley catheter, a surgical drain or a nasogastric tube, your surgical care team will try to get these out as soon as possible (usually 24 to 48 hours after surgery) to reduce the risk for infection. Some may go home with a drain, based on their procedure.
- Pain management. For medication, opioids are no longer the first choice. Other options include acetaminophen, an over-the-counter or prescription-strength nonsteroidal anti-inflammatory drug or gabapentin.
In many cases, these non-narcotic options may be as effective as an opioid. Opioids, if needed, may be used for “breakthrough” pain (a pain flare-up that occurs despite the regular use of pain medication). You may also be given a local anesthesia patch to wear.
Recovery at home
Your discharge instructions will depend on the type of surgery you have, but opioids will not be an automatic part of the plan. A non-narcotic pain reliever will be the first choice.
If you need an opioid for breakthrough pain, you will be prescribed the lowest effective dose for a shorter amount of time. For example, instead of a 10-day prescription, you may get a three-to-five-day prescription. Your ERAS plan will include follow-up phone calls from the nurse or the nurse practitioner to see how you are doing and how you are handling any pain.
If you are scheduled for surgery: Ask your surgeon if your hospital has an ERAS program. To learn more about ERAS, go to the website of the ERAS Society USA, ERASUSA.org.