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Does An Eras Protocol Reduce Post-Operative Opiate Prescribing In Plastic Surgery?
Heather R. Faulkner, MD, MPH1,2, Bridget N. Kelly, BA1, Suzanne B. Coopey, MD1,2.
1Massachusetts General Hospital, Boston, MA, USA, 2Harvard Medical School, Boston, MA, USA.

Purpose
There is an opiate crisis in the United States. Opiate prescribing post-operatively can influence patient use and increase the risk of opiate dependence and addiction. ERAS (Enhanced Recovery After Surgery) protocols have been used extensively in general surgery to reduce opiate use. These protocols have expanded into the field of plastic surgery. This study's purpose is to determine if the use of an ERAS protocol can significantly reduce opiate prescribing for patients undergoing plastic and reconstructive operations.
Methods
After literature review on existing ERAS protocols, an ERAS protocol was designed and instituted to be used on consecutive patients undergoing any operation (reconstructive and cosmetic, inpatient and outpatient) by a single academic plastic surgeon. The protocol consisted of: pre-operative same-day single doses of oral acetaminophen and gabapentin (dosed for age and gender) and post-operative oral acetaminophen (around the clock for 24-48 hours followed by as needed dosing), gabapentin (low dose) twice a day for 7-14 days, ibuprofen as needed, oxycodone as needed. The Massachusetts Prescription Monitoring Program (MA-PMP) database provides quarterly reports on individual prescribing of Schedule II-V drugs. Prescribing for a single surgeon was compared in the time period before and after ERAS protocol institution. Data were analyzed using Stata/IC 15.1. Two-sample t-tests were used for mean comparison.
Results
The MA-PMP provided individual prescriber data in the form of a quarterly report which was accessed online. The surgeon writes prescriptions for outpatient cases, most post-operative clinic patients, and some inpatients. Other prescriptions are written by an advanced practice provider. The ERAS protocol was in place on all patients starting in October 2018. Pre-ERAS months (July-September 2018) were compared to the same time period (July-September 2019) 1 year after ERAS protocol implementation. Within the report there were 19 patients in the pre-ERAS group and 21 patients in the post-ERAS group, which represented 50% of the surgeon's volume during those time periods. Mean daily Morphine Milligram Equivalent (MME) per patient pre-ERAS was 68.5 (range 43.6103.3), and post-ERAS was 45.2 (range 41.9-47.9) (p=0.0015). Mean duration of opiate prescription per patient pre-ERAS was 7.6 days (range 3.7-14.5), and post-ERAS was 3.1 days (range 2.7-3.7) (p=0.0012). Mean quantity prescribed to each patient pre-ERAS was 32 pills (range 16-62), and post-ERAS was 13.7 pills (range 13-15), (p=0.0025). Number of opiate/controlled substance prescriptions per patient pre-ERAS was 1.3 (range 1.2-1.5), and post-ERAS was 1.1 (range 1-1.2) (p<0.001).
Conclusions
Implementation of a pre-operative and post-operative ERAS protocol is a viable method of reducing opiate prescriptions for patients undergoing plastic and reconstructive surgery. Patients and providers can benefit from education about ERAS protocols. In the current state of the opiate crisis, this is an easy strategy to introduce and replicate in a variety of practice settings.


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