Miami Thoracic Surgeons Achieve Pain Control With Minimal or No Opioids Interview with:
Dao Minh Nguyen, MD, MSc FRCSC FACS
Thoracic Cancers Group Go-Lead
Sylvester Comprehensive Cancer Center
University of Miami Miller School of Medicine What is the background for this study?

Response: Patients undergoing thoracic surgery operations experience significant acute incisional pain as well as chronic pain many months after.

The mainstay of treatment is based on frequent use of potent and addictive-prone opioids such as hydromorphone, oxycodone at high dosages and long duration.
There is a high incidence of persistent opioid users and chronic opioids users in surgical patient population. This certainly contributes to the opioid epidemic in the USA and worldwide.

We implemented a peri-operative care protocol for patients undergoing thoracic surgery operations called Enhanced Recovery after Thoracic Surgery (ERATS). The overarching goal of ERATS is to streamline care for thoracic surgery patients particularly in the postoperative period to mitigate pain with opioid-free strategy, to minimize postoperative complications, rapid return to baseline states and safe, early discharge home. This protocol follows guidelines of the ERAS principles and is developed for thoracic patients to address their unique needs.

Once pain is adequately addressed with opioid-free strategy with elimination of opioid-associated side effects, rapid recovery after surgery can be achieved.

We routinely perform intraoperative intercostal nerve blocks under direct vision by infiltrating the soft-tissue surrounding 9 to 10 intercostal nerves with long-acting local anesthetic agent Exparel® admixed with the rapid-acting anesthetic agent bupivacaine. This is a form of regional analgesia. We also infiltrate the skin incisions with the local anesthetic mixture. Patients are prescribed schedule round-the-clock oral non-opioid analgesics Tylenol, gabapentin and a non-steroidal anti-inflammatory drugs (NSAIDs) such Toradol, Motrin or Celebrex. Mild opioid such as Tramadol and low-dose of oxycodone are available on needed-basis for rescue pain management.

This ERATS protocol was implemented in February 2018 and is our main postoperative care protocol ever since. Its performance was regularly reviewed, and protocol updated to achieve optimal postoperative outcomes. The optimized ERATS protocol was implemented in 1/1/2020. What are the main findings?

Response: We observed that patients cared by this optimized protocol have less pain, use less opioid in hospital and have shorter length of stay and lower rates of complications. That prompted us to do this study to objectively and quantitatively assess the opioid utilization in the postoperative period (both in-hospital and after discharges) of optimized ERATS patients.

The main findings are 60% of patients were discharged home after a major thoracic operations without opioid prescriptions, the remaining 40% only use low dose of opioids mainly the mild non-addictive synthetic opioid tramadol. Patients of the entire cohort described average postoperative pain of 2 (range 0-3) using a 0-to-10 scale (0: no pain, 10: most excruciating pain). They use an equivalent of 1 to 1.5 tablets of 5-mg oxycodone. Those patients going home without the need of opioid prescriptions had much less pain and use little if at all any opioid while in hospital.

Another important finding is the very low rate of persistent opioid use (defined as opioid use within 180 days of the index operation) compared to those discharged with opioid prescriptions and did fill them for use. The significance of this study is to demonstrate that opiod-free pain management after thoracic surgery is possible in most of our patients, less prolonged need for opioid in this subgroup of patient population our ability to identify clinico-demographic factors associated with opioid-free discharges that can be exploited to increase even higher incidence of opioid-free patient population What should readers take away from your report?

Response: Thoracic surgery does not have to be painful. Our pain management strategy is practically opioid-free. Patients no longer rely on high doses of opioid for postoperative pain control. What recommendations do you have for future research as a result of this study?

Response: Future research should focus on strategy to minimize or eliminate opioid use for management postoperative acute pain

Disclosures: We have no conflict of interests to declare. We disclose that use Exparel® for nerve block which is off-label.

Daniel J. Gross, Ahmed Alnajar, Nestor R. Villamizar, Dao M. Nguyen,Achieving opioid-free discharge following robotic thoracic surgery: A single-institution experience,JTCVS Open,Volume 15,2023,
Pages 508-519,ISSN 2666-2736,

The information on is provided for educational purposes only, and is in no way intended to diagnose, cure, endorse or treat any medical or other condition. Always seek the advice of your physician or other qualified health and ask your doctor any questions you may have regarding a medical condition. In addition to all other limitations and disclaimers in this agreement, service provider and its third party providers disclaim any liability or loss in connection with the content provided on this website.

Last Updated on October 3, 2023 by