Enhanced Recovery After Thoracic Surgery: Postoperative Opioid Use by Preoperative Use Status and Risk Factors for New Persistent Opioid Use

Enhanced recovery after surgery (ERAS) is associated with improved outcomes in thoracic surgery. Opioid-sparing analgesia is a key component of ERAS, but the effect based on preoperative opioid use is not well understood. This study aimed to evaluate the effects of ERAS based on preoperative opioid use and identify factors associated with new persistent opioid use (NPOU). A prospectively maintained database of patients undergoing pulmonary resection was linked to the regional prescription drug monitoring program. Patients were stratified by preoperative opioid prescriptions filled in the preceding 12-months (naïve or non-naive) and evaluated before and after ERAS implementation. A subset of NPOU were also evaluated. Of the 371 patients included, 59.6% were naïve and 40.4% non-naïve to opioids preoperatively. ERAS was associated with reduction in total inpatient and discharge prescription morphine milligram equivalents in both groups, and average inpatient morphine milligram equivalents was reduced in non-naïve users. In naïve users, ERAS was associated with shorter length of stay and shorter chest tube duration. Of the 221 naïve users, 10.9% were identified with NPOU postoperatively, and the rate of NPOU did not change with ERAS implementation. An ERAS protocol was associated with reduced opioid use in patients undergoing pulmonary resection regardless of preoperative opioid use status. However, a subset of naïve users developed NPOU despite similar postoperative courses. Strategies are needed to identify risk factors and individualize pain management in this population.