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Including Patients on Preoperative Opioids in Enhanced Recovery After Surgery Programs and Research: Are We Ready?

To the Editor Edwards et al 1 and the Perioperative Quality Initiative (POQI)-4 research group highlight a lack of high-quality evidence on the perioperative care of patients who take opioid analgesics. The authors present recommendations for managing this population of high-risk patients within the framework of existing enhanced recovery programs. They propose a standard taxonomy for classifying preoperative opioid use, which is an important and necessary step for further research in this field. Patients on opioids present an issue for Enhanced Recovery After Surgery (ERAS) pathways because they often require complex care tailored to the patient’s unique needs and can strain limited program resources. ERAS pathways have traditionally been organized by surgery type, making implementing modifications for specific patient populations challenging to apply across different pathways. More research is needed on the feasibility of including patients on preoperative opioids into ERAS programs. However, the drive toward opioid-sparing and opioid-free ERAS pathways2 may create incentives for programs to exclude these patients from clinical trials. This may be more evident in trials that have opioid consumption and pain as primary outcomes. In a meta-analysis on ERAS randomized controlled trials that included pain reduction as an outcome, 15 of 21 (71.4%) of the included articles explicitly excluded patients taking opioids before surgery.3 However, in a Guohua Li, MD, DrPH Department of Anesthesiology Columbia University College of Physicians and Surgeons New York, New York Department of Epidemiology Columbia University Mailman School of Public Health New York, New York