Implementation of a Non-opioid Protocol Following VATS Lobectomy Improves Pain Scores and Decreases Cost of Care

Purpose: Non-opioid protocols in thoracic surgery have been shown to decrease opioid prescriptions without increasing pain. Adoption has been limited by the cost of medications used in these protocols, notably liposomal bupivacaine. The purpose of this study was to compare outcomes, including cost, before and after implementation of a non-opioid protocol.

Methods: All patients undergoing non-robotic, video-assisted thoracoscopic (VATS) lung lobectomy at a single institution between 2016-2022 were included in this study. Data were obtained from the Society of Thoracic Surgeons General Thoracic Surgery Database and hospital records. In January 2019, we implemented a non-opioid protocol which consisted of an intraoperative intercostal block using liposomal bupivacaine and scheduled perioperative acetaminophen, gabapentin, and methocarbamol. Opioid pain medication was available for breakthrough pain, and post-discharge opioid prescriptions were given only as needed. Patients were divided into a standard regimen group (2016-2018) and a non-opioid regimen group (2019-2022) and preoperative factors, opioid usage, pain scores, cost, and postoperative outcomes were compared between the two groups. Opioid usage was standardized as morphine milligram equivalents. Costs were adjusted for inflation using US Bureau of Labor Statistics inflation data. P-values less than 0.05 were considered statistically significant.

Results: There were 376 patients who met inclusion criteria for this study, of which 173 received the standard regimen and 203 received the non-opioid regimen. Non-opioid regimen patients were older (67.6 [SD 8.4 years] versus 64.6 [SD 9.4 years]; p< 0.01) and more likely female (59.6% versus 48.6%; p=0.04). There were no differences between groups in race, smoking status, or comorbidities. All patients in the non-opioid regimen group received at least one component of the medication regimen, and 89.7% received all four components. 98.5% of these patients received the intercostal block. There was a significant decrease in oral and intravenous opioid usage following implementation of the non-opioid protocol, along with improvement of pain scores (see Figure 1). The percentage of patients receiving any opioid medication from postoperative day 1-7 decreased from 98.8% to 41.4% (p < 0.01), and the percentage of patients receiving an opioid prescription at discharge decreased from 94.2% to 29.1% (p < 0.01). There were no differences between groups in case length or 30-day readmission rate. While there was an increased median pain medication cost in the non-opioid regimen group, total encounter costs were significantly less compared with the standard regimen group. See Table 1 for all resource utilization outcomes.

Conclusion: Implementation of a non-opioid protocol for patients undergoing VATS lung lobectomy decreases opioid usage while improving pain scores. Despite increased costs of non-opioid pain medications, there is an overall decrease in total hospital costs for these patients. Adoption of non-opioid protocols for this procedure benefits patients and improves resource utilization.

Identify the source of the funding for this research project: None