Program Reduces Opioid Dependence in Lung Cancer Patients

Study shows that thoracic surgeons who use the ERATS protocol increase the likelihood of earlier hospital discharge with a nearly opioid-free recovery.

Researchers at Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine found that robot-assisted surgeries and new patient-care protocols enable lung cancer surgery patients to go home earlier, with less pain and almost always without a need for potentially addictive opioids.

The ERATS protocol — Enhanced Recovery After Thoracic Surgery — introduced at the University of Miami Health System in 2018, was created to achieve optimal outcomes for patients undergoing thoracic surgical procedures, most of which treat lung cancers. The ERATS protocol, which has been refined twice, is similar to guidelines initiated at some other medical centers.

“We’ve seen a significant reduction of opioid use both in-hospital and after discharge following robotic thoracoscopic procedures,” said Sylvester Thoracic Cancers Group co-leader Dao Nguyen, M.D., a thoracic surgeon who treats and studies lung and other cancers.

“Additionally, length of hospitalization has gone down, with an average one-and-a-half-day stay for less complicated procedures and a two-and-a-half day stay for major procedures, such as lobectomies and segmentectomies. The national average for the more complex procedures is about four to five days,” said Dr. Nguyen, senior author of an article published in the Journal of Thoracic and Cardiovascular Surgery Open.

Effective Pain Control

Before the implementation of ERATS, powerful opioids were often used among other options for controlling the pain that’s intrinsic to all chest surgery procedures, whether open or minimally invasive, but negative side effects were common. While all components of ERATS are important and they work synergistically to improve patient outcomes, effective pain control is the cornerstone of the protocol, the authors said.

They found they could drastically reduce patients’ postoperative need for potent and potentially addictive opioid drugs like oxycodone and hydromorphone by using intercostal nerve blocks — injections of medication under the ribs — that combine a long-acting local anesthetic with a fast-acting, short-duration one. Patients also are given safe, nonaddictive pain relievers like ibuprofen, acetaminophen and gabapentin. The authors said optimal pain control, in addition to reducing reliance on opioids, helps patients start moving more quickly, experience more effective chest physical therapy, have fewer complications and enjoy an improved sense of well-being.

Results of Protocol

Patients’ pain levels have gone down as ERATS has evolved, with the greatest pain control achieved after the latest refinement in January 2020, according to the study.

“On the day of discharge, patients reported pain levels of zero to two or three on the numeric pain rating scale, where 10 denotes the most severe pain imaginable,” Dr. Nguyen said.

The single-institution, retrospective study of patient records included 466 patients who underwent surgery performed by thoracic surgeons in the DeWitt Daughtry Department of Surgery at the University of Miami. Of the 466, 211 patients underwent complex, major operations, and 255 had less complicated procedures performed. In all, 309 patients were discharged with no opioid prescriptions, and of these, 275 remained opioid-free. Of the 157 patients discharged with prescriptions for oxycodone and/or the nonaddictive synthetic opioid tramadol for up to three days, 150 patients filled the prescriptions; seven did not.

Overall, the researchers found:

• About 60% of patients (282) were discharged home without the need for oral opioids and remained opioid-free.
• Only 11% of 275 patients (34) discharged without opioid prescriptions later needed one — a single fill of tramadol, a nonaddictive drug.
• Seven of 157 patients (11%) who went home with handwritten prescriptions for opioids never filled them.

“Further analysis found that only 3% of patients would require opioids for reasons related to their operations over the next 180 days,” Dr. Nguyen said. “This is in contrast to the 10% of patients, a statistically significant difference, who need opioids in the post-discharge period and become persistent opioid users. Achieving nearly opioid-free post-discharge status — thanks in large part to robotic thoracic surgery — minimizes opioid availability and contributes to the fight against the opioid epidemic.”

Dr. Nguyen is the senior and corresponding author of the study. Daniel Gross, M.D., is the first author. Co-authors are Ahmed Alnajar, M.D., M.S.P.H., and Nestor Villamizar, M.D.

Tags: Dr. Dao Nguyen, lung cancer surgery, Sylvester Comprehensive Cancer Center, thoracic surgery