For the researchers, the primary objective behind implementing the ERATS protocol is to achieve predictable and optimal postoperative results. This involves employing a multimodal approach to pain management that minimizes opioid use, reduces postoperative complications to a minimum, achieves a brief (shortest possible) hospital stay and safest possible discharges without readmissions, ensures patient comfort and contentment, and optimizes cost-effectiveness. 

“Prior to ERATS, strong opioids such as oxycodone (Roxicodone) or hydromorphone (Dilaudid) (schedule II) were frequently used for acute postoperative pain, but this approach often led to a high incidence of side effects reported,” said Ahmed Alnajar, M.D., M.S.P.H. co-author of the study. Additionally, these strong opioids have a high tendency to create dependency and are prone to abuse.

“Since the implementation of our newest version of the ERATS protocol in January 2020, we have achieved a rate of 60% opioid-free discharge following elective robotic thoracic procedures of diverse indications,” he added.

Researchers conducted a retrospective analysis using data from a thoracic surgery database and electronic medical records at the University of Miami Hospital. The study looked at how ongoing improvements to ERATS affect how often patients can be discharged without needing opioids.

The study focused on patients who underwent robotic thoracic surgical procedures between January 2020 and December 2021 and met specific criteria: adult patients, opioid-naïve, and undergoing elective robotic video-assisted thoracoscopy for specific pulmonary or mediastinal procedures. 

Patients were given post-discharge instructions and prescriptions for opioids (schedule II oxycodone and/or schedule IV tramadol) based on factors like pain management discussions, pain levels on the day of planned discharge from the hospital, and opioid requirements during hospitalization. 

A total of 466 opioid-naïve patients were included in the analysis. The primary goal was to identify factors associated with opioid-free discharge while determining the occurrence of new persistent opioid users. 

Results showed that 66% of patients were discharged without receiving opioids, although 11% of them required opioid prescriptions after discharge. Interestingly, 11% of patients who were prescribed opioids at discharge never actually filled their prescriptions, accentuated Dr. Alnajar, who is a graduate of the M.S.P.H program in the Department of Public Health Sciences. 

Factors linked to opioid-free discharge included certain types of surgical procedures (nonanatomic resections and mediastinal procedures), minimal pain, and not using opioids on the day of discharge. 

Notably, only 3.2% of patients discharged without opioids became new persistent opioid users, compared to 10.8% of patients who filled opioid prescriptions after discharge. Additionally, only 2.3% of the entire cohort of opioid-naïve patients became chronic opioid users, and the frequency of chronic use did not differ significantly based on whether opioids were prescribed at discharge. 

The study underscores the effectiveness of optimized opioid-sparing ERATS protocol in decreasing opioid prescriptions upon discharge. It also highlights the low rate of both persistent and chronic opioid use among patients, underscoring the role of ERATS protocols in combating the opioid epidemic. 

Other University of Miami collaborators include Daniel J. Gross, M.D., primary author, Nestor R. Villamizar, M.D., Dao M. Nguyen, M.D., M.Sc., FRCSC FACS, senior author.

Written by Deycha Torres Hernández

Published on August 22, 2023