Effect of an Acetaminophen-based Pain Management Protocol without Controlled Substances after Bariatric Surgery on In-Hospital and Post-Discharge Opioid Usage
Shruthi Rajkumar, Elana Davidson, Michael Bell, Yannis Raftopoulos
Holyoke Medical Center, Holyoke, MA
Background: Best-reported outcomes of enhanced recovery protocols after bariatric surgery include a reduction of mean oral morphine equivalent (OME) to 10.5 mg and post-discharge opioid prescriptions (PDOP) to 65% at the expense of using other Federal or State-controlled substances (CS) like pregabalin and gabapentin or NSAIDs, none of which are risk-free. An entirely opioid-free in-hospital recovery (OFIHR) remains unknown.
Methods: This is a prospective 6-year longitudinal study on 711 patients who underwent LSG, LRYGB, or revisions. Analgesia was achieved with intravenous acetaminophen and hydromorphone and fentanyl as rescue medications in-hospital, and oral acetaminophen post-discharge.
Results: Mean total in-hospital opioid usage in OME (TIH_OME) was 5.4 mg. Of 342/711 (48.1%) patients who had OFIHR, one received gabapentin. NSAIDs or pregabalin were not used. IHOU was required in 153 (21.5%) and 292 (41.1%) patients in recovery room and surgical floor respectively. OFIHR patients had shorter hospital stay (1.02 vs 1.11 days, p=.0002) and lower 0-24hr pain scores (p<.0001). Post-discharge, 15/711 (2.1%) received CS of which eight were chronic opioid users (COU), thirteen had chronic pain and one had opioid abuse history (OAH). Independent associations of TIH_OME were found inversely with BMI and linearly with zero-hour pain score, OAH, COU, and PDOP on multiple regression analysis (p <.0001). Surgery type had no independent effect on TIH_OME or PDOP. PDOP, but not TIH_OME, correlated with COU (p=0.0002).
Conclusion: An unprecedented reduction of IHOU to 5.4 mg OME and post-discharge opioid prescriptions to 2% was achieved, while half of the patients had an OFIHR without NSAIDs or CS.
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