Impact of broadly targeted enhanced recovery after surgery protocols in hysterectomy versus other gynecologic surgeries

The opioid epidemic in the United States poses a major public health challenge, with postoperative prescribing recognized as a significant source of initial opioid exposure. Midwestern states, including Iowa, have experienced substantial opioid-related morbidity and mortality, reflecting broader national trends of opioid misuse, diversion, and overdose. Excess postoperative opioid prescribing increases the availability of unused medications, which are often retained in households and pose ongoing risks for diversion and nonmedical use. These challenges highlight the need for effective, scalable strategies to reduce opioid exposure at surgical discharge. Accordingly, this study investigated the impact of a broadly targeted Enhanced Recovery After Surgery (ERAS) pathway on opioid prescribing at discharge for hysterectomy patients compared to other gynecologic procedures.

A retrospective chart review was conducted across six Iowa hospitals implementing the "Billion Pill Pledge" ERAS pathway. Two groups of patients underwent surgery between November 3, 2022 and April 4, 2024: those undergoing hysterectomy (n = 63) and those undergoing other gynecologic surgeries (n = 30), including cervical hysteroscopy, cesarean section, endometriosis excision or ablation, and sterilization procedures. Pre-ERAS and post-ERAS implementation data from the postoperative period were analyzed between the two groups in terms of average opioid pill counts prescribed, percent reduction in pill counts prescribed after ERAS implementation, and percent of prescribed pills remaining unused.

Pre-ERAS data showed no significant difference in mean opioid pill counts prescribed at discharge between hysterectomies and other gynecologic surgeries (p = 0.3). Post-ERAS data displayed significantly higher mean pill counts for hysterectomies (23 pills) versus other gynecologic surgeries (16 pills) (p < 0.001). Patient-reported post-ERAS prescription quantities were significantly lower than surgeon-estimated pre-ERAS prescribing quantities for both hysterectomies (27 pills versus 23 pills) (p < 0.001) and other gynecologic surgeries (29 pills versus 16 pills) (p < 0.001). The hysterectomy group had a significantly smaller percent reduction in prescribed pill counts than the other gynecologic group (14% versus 40%) (p < 0.001). There was no significant difference in the proportion of prescribed pills left unused between the hysterectomy group (55%) and the other gynecologic group (65%) (p = 0.08). No prescription refills were reported within 30 days postoperatively.

Patient-reported opioid prescription quantities prescribed at discharge following implementation of the Billion Pill Pledge ERAS pathway were significantly lower than surgeon-estimated pre-ERAS prescribing quantities across gynecologic surgeries, with a larger difference observed among non-hysterectomy procedures. Despite lower post-ERAS prescription quantities, over half of prescribed pills on average remained unused, highlighting the need for ongoing efforts to optimize postoperative opioid disposal practices. These findings suggest that broadly targeted ERAS pathways may be associated with lower postoperative opioid prescribing in gynecologic surgery.