Gabapentin Decreases Narcotic Usage: Enhanced Recovery after Surgery Pathway in Free Autologous Breast Reconstruction

Enhanced recovery after surgery (ERAS) was described by Denmark surgeon, Henrik Kehlet, in 1997.1 ERAS protocols employ a multimodal, multidisciplinary approach to surgical patient care that aims to decrease perioperative stress, increase quality of care, and expedite recovery. Various core elements of ERAS care throughout the preadmission, preoperative, intraoperative, and postoperative process are critical to success.2 The ERAS pathway was initially used in the setting of colorectal surgery, but has been shown to improve outcomes in many other surgical specialties.2–7 In microsurgical breast reconstruction, the ERAS pathway reduces pain scores, opioid use, and length of stay, resulting in significant cost savings, without increasing complication rates compared with traditional postoperative care.8–12 Furthermore, ERAS strategies result in earlier mobilization, decreased nausea, and increased patient satisfaction.13,14 Such discussion is highly relevant in light of the opioid epidemic facing the United States.15–17 Spurred by the introduction of pain as a fifth vital sign and fueled by pharmaceutical companies, sales of oxycodone and methadone quadrupled between 1997 and 2002.18 Opioid-related deaths are at an all-time high with 115 Americans dying each day from overdoses in 2016; 40% of these deaths are the result of prescription opioids.15 The US Department of Health and Human Services has declared the opioid crisis a public health emergency making reevaluation of postsurgical prescribing practices critical at this juncture.17 Although it has been well established that the benefits of ERAS protocols for microvascular breast reconstruction are manifold,8–12 the contribution of each component within the ERAS pathway in decreasing narcotic usage remains to be deciphered.10,11 Most studies attribute the success of the protocol to the synergistic multimodal therapies bestowing homeostasis after surgical stress, without delineating the effects of each individual item.10,11 We present our experience in implementing our ERAS protocol in autologous breast reconstruction patients and the effect on opioid use, pain scores, and doses of antiemetic medications. Furthermore, we seek to examine the contribution of each modality within the ERAS protocol to reduce narcotic usage and postoperative nausea vomiting. Understanding the components critical in reducing postoperative opioid use will enhance the application of ERAS protocols.