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Introduction: Opioid overprescription after colorectal surgery can lead to adverse events, persistent opioid use, and diversion of unused pills. This study aims to assess the extent to which opioids prescribed at discharge after elective colorectal surgery are consumed by patients., Methods: This prospective cohort study included adult patients (≥ 18 yo) undergoing elective colorectal surgery at two academic hospitals in Montreal, Canada. Patients completed preoperative questionnaires and data concerning demographics, surgical details, and perioperative care characteristics (including discharge prescriptions) were extracted from electronic medical records. Self-reported opioid consumption was assessed weekly up to 1-month post-discharge. The total number of opioid pills prescribed and consumed after discharge were compared using the Wilcoxon signed-rank test. Negative binomial regression was used to identify predictors of opioid consumption., Results: We analyzed 344 patients (58 ± 15 years, 47% female, 65% laparoscopic, 31% rectal resection, median hospital stay 3 days [IQR 1-5], 18% same-day discharge). Most patients received a TAP block (67%). Analgesia prescription at discharge included acetaminophen (92%), NSAIDs (38%), and opioids (92%). The quantity of opioids prescribed at discharge (median 13 pills [IQR 7-20]) was significantly higher than patient-reported consumption at one month (median 0 pills [IQR 0-7]) (p < 0.001). Overall, 51% of patients did not consume any opioids post-discharge, and 63% of the prescribed pills were not used. Increased opioid consumption was associated with younger age (IRR 0.99 [95%CI 0.98-0.99]), higher preoperative anxiety (1.02 [95%CI 1.00-1.04]), rectal resections (IRR 1.45 [95%CI 1.09-1.94]), and number of pills prescribed (1.02 [95%CI 1.01-1.03])., Conclusion: A considerable number of opioid pills prescribed at discharge after elective colorectal surgery are left unused by patients. Certain patient and care characteristics were associated with increased opioid consumption. Our findings indicate that post-discharge analgesia with minimal or no opioids may be feasible and warrants further investigation., Competing Interests: Declarations. Disclosures: Dr. Julio F. Fiore Jr, Ghadeer Olleik, Maxime Lapointe-Gagner, Shrieda Jain, Dr. Samin Shirzadi, Philip Nguyen-Powanda, Dr. Sarah Al Ben Ali, Tahereh Najafi Ghezeljeh, Hiba Elhaj, Dr. Naser Alali, Dr. Francesca Fermi, Makena Pook, Dr.Christos Mousoulis, Dr. Ahmad Almusaileem, Dr. Nardin Farag, Katy Dmowski, Danielle Cutler, Pepa Kaneva, Dr. Marylise Boutros, Dr. Lawrence Lee, Dr. Ramanakumar V Agnihotram, and Dr. Liane Feldman have no conflicts of interest or financial ties to disclose in relation to this study., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Low adherence to enhanced recovery pathways (ERPs) may negatively affect postoperative outcomes. The objective of this study was to assess the extent to which patient activation (PA, i.e., knowledge, skills, and confidence to participate in care) is associated with adherence to an ERP for colorectal surgery., Methods and Procedures: This cohort study included adult patients (≥ 18 yo) undergoing in-patient elective colorectal surgery at two university-affiliated hospitals in Montreal, Canada. Preoperatively, patients completed the Patient Activation Measure (PAM) questionnaire (score 0-100, categorized into low PA [≤ 55.1] vs. high PA [≥ 55.2]). All patients were managed with an ERP including 15 interventions classified into 2 groups: those requiring active patient participation (5 active ERP interventions, including early oral intake and mobilization) and those directed by the clinical team (10 passive ERP interventions, including early termination of IV fluids and urinary drainage). The adjusted association between PA and ERP adherence was evaluated using linear regression., Results: A total of 286 patients were included (mean age 59 ± 15 years, 45% female, 62% laparoscopic, 33% rectal, median length of stay 4 days [IQR 2-6]). Most patients had high levels of PA (74%). Mean adherence was 90% (95% CI 88-91%) for passive ERP interventions and 72% (95% CI 70-75%) for active interventions. On regression analysis, high PA was associated with increased adherence to active ERP interventions (+ 6.8% [95% CI + 1.1 to + 12.5%]), but not to passive interventions (+ 2.5% [95% CI - 0.3 to + 5.3%]). Increased active ERP adherence was associated with reduced length of stay, 30-day complications, and hospital readmissions., Conclusion: This study supports that high PA is associated with increased adherence to ERP interventions, particularly those requiring active patient participation. Preoperative identification of patients with low activation may inform interventions to optimize patient involvement with ERPs and improve postoperative outcomes., Competing Interests: Declarations. Disclosures: Dr. Julio F. Fiore Jr, Dr. Sarah Al Ben Ali, Dr. Francesca Fermi, Ghadeer Olleik, Maxime Lapointe-Gagner, Shrieda Jain, Philip Nguyen-Powanda, Dr. Tahereh Najafi Ghezeljeh, Hiba Elhaj, Dr. Naser Alali, Mak Pook, Dr. Christos Mousoulis, Saba Balvardi, Dr. Ahmad Almusaileem, Katy Dmowski, Danielle Cutler, Pepa Kaneva, Dr. Marylise Boutros, Dr. Lawrence Lee, and Dr. Liane S Feldman have no conflicts of interest or financial ties to disclose in relation to this study., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Excessive opioid prescribing after surgery has contributed to the current opioid crisis; however, the value of prescribing opioids at surgical discharge remains uncertain. We aimed to estimate the extent to which opioid prescribing after discharge affects self-reported pain intensity and adverse events in comparison with an opioid-free analgesic regimen., Methods: In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, Scopus, AMED, Biosis, and CINAHL from Jan 1, 1990, until July 8, 2021. We included multidose randomised controlled trials comparing opioid versus opioid-free analgesia in patients aged 15 years or older, discharged after undergoing a surgical procedure according to the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity definition (minor, moderate, major, and major complex). We screened articles, extracted data, and assessed risk of bias (Cochrane's risk-of-bias tool for randomised trials) in duplicate. The primary outcomes of interest were self-reported pain intensity on day 1 after discharge (standardised to 0-10 cm visual analogue scale) and vomiting up to 30 days. Pain intensity at further timepoints, pain interference, other adverse events, risk of dissatisfaction, and health-care reutilisation were also assessed. We did random-effects meta-analyses and appraised evidence certainty using the Grading of Recommendations, Assessment, Development, and Evaluations scoring system. The review was registered with PROSPERO (ID CRD42020153050)., Findings: 47 trials (n=6607 patients) were included. 30 (64%) trials involved elective minor procedures (63% dental procedures) and 17 (36%) trials involved procedures of moderate extent (47% orthopaedic and 29% general surgery procedures). Compared with opioid-free analgesia, opioid prescribing did not reduce pain on the first day after discharge (weighted mean difference 0·01cm, 95% CI -0·26 to 0·27; moderate certainty) or at other postoperative timepoints (moderate-to-very-low certainty). Opioid prescribing was associated with increased risk of vomiting (relative risk 4·50, 95% CI 1·93 to 10·51; high certainty) and other adverse events, including nausea, constipation, dizziness, and drowsiness (high-to-moderate certainty). Opioids did not affect other outcomes., Interpretation: Findings from this meta-analysis support that opioid prescribing at surgical discharge does not reduce pain intensity but does increase adverse events. Evidence relied on trials focused on elective surgeries of minor and moderate extent, suggesting that clinicians can consider prescribing opioid-free analgesia in these surgical settings. Data were largely derived from low-quality trials, and none involved patients having major or major-complex procedures. Given these limitations, there is a great need to advance the quality and scope of research in this field., Funding: The Canadian Institutes of Health Research., Competing Interests: Declaration of interests JFF declares receiving research funding from Merck and honorarium from Shionogi outside the submitted work. LSF declares receiving research funding from Merck and Johnson & Johnson outside the submitted work. LL declares receiving research funding from Johnson & Johnson outside the submitted work. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)