When Homer Travis was discharged from the hospital after previous surgeries, he asked for narcotic painkillers "just in case" — and needed to use them.

But that changed last November, when he underwent colorectal surgery through a new approach at Cleveland Clinic Akron General in which no narcotics are used during or after some operations.

Travis never needed the strong painkillers after the surgery, which removed 14 inches of his colon and left him with a 12-inch incision from his sternum to his belly.

"I took nothing but Tylenol," said Travis, 67, of Barberton, who was willing to go along with the new technique, but wasn't sure it would work.

When Travis was invited earlier this year to talk about his surgery to a group of doctors and nurses, he brought his bottle of 20 unused Vicodin and handed it to his surgeon. Travis had asked for the painkillers "just in case" when he was discharged.

"If we can get rid of pain pills, that's what I want. They always made me groggy and kind of in a fog," said Travis, who has had two knee replacements, bariatric and hernia surgery and also had his appendix and gallbladder removed.

Doctors at Akron General and cross-town rival Summa Health are opting to forgo powerful and potentially addictive opiates for pain control during and after surgeries in favor of narcotic-free options.

The approach, known as Enhanced Recovery After Surgery, turns on its head what doctors and nurses had advised for years: Don't eat or drink before surgery, use pain medications — including narcotics — for comfort and stay in bed to recover.

Proponents of the ERAS approach say it decreases hospital stays and gets patients back on their feet quicker. And an added bonus is it significantly reduces and in many cases eliminates the use of narcotics used during the hospital stay or after — a positive in the fight against the growing national opioid epidemic.

New anesthesia techniques and medications have become available, allowing nerve blocks that provide longer-lasting relief from pain during and after the surgery, said Dr. Mark Horattas, Akron General's chairman of surgery. Patients using ERAS techniques also are instructed to drink a Gatorade several hours before their surgery to keep them hydrated — a switch from the typical orders to avoid liquids in the hours before surgery.

When Travis woke up from surgery, for example, he was encouraged to start chewing gum to increase his saliva and encourage the return of bowel functions.

Europe uses approach

ERAS protocols have been in use in different forms for about 20 years, but until more recent years have mostly been utilized in Europe, said Dr. Tonia Young-Fadok, a professor of surgery at Mayo Clinic Arizona and president of the board of the ERAS Society USA chapter.

"Adoption is still in its relative infancy in the U.S.," said Young-Fadok, but it's gaining traction. The society is holding its first conference next week in Dallas.

The reduction or elimination of narcotics is especially helpful for patients with colorectal problems because narcotics can slow bowel movement from returning after surgery, causing a longer recovery, she said.

To have two major hospital systems in one town both using ERAS techniques is "fantastic," said Young-Fadok.

"There's a fine balance when an institution is looking at doing this. If you've got just one interested person, it's very hard to get this up and running. It's also a balance between someone being young enough to be open-minded and senior enough to hold some sway in the hospitals so things actually get done," said Young-Fadok.

Growth in protocol

Summa Health started using the Enhanced Recovery After Surgery protocol in 2013 and has been increasing its usage, said Dr. Tom Mark, chair of the department of anesthesiology.

At Summa, the non-narcotic ERAS options have been offered in a wide variety of surgeries, including mastectomies and other breast surgeries and hysterectomies, colorectal surgeries, all gastric-bypass patients, laparoscopic surgeries, liver and gallbladder surgeries and appendectomies. They also are used in thoracotomies and orthopedic cases, Mark said.

Akron General began using ERAS techniques in its colorectal surgeries in 2016 and found great successes, Horattas said.

It has been expanded to breast and bariatric surgery, with more departments exploring it, and the team has been working on developing the program to other parts of the Cleveland Clinic. The Clinic recently listed ERAS techniques as its No. 8 medical innovation for the health system. Horattas last week was at the American College of Surgeons meeting presenting the hospital's ERAS results.

In 2016, 30 percent of colorectal surgical patients at Akron General didn't receive any narcotics before, during or after their surgery or when they went home, said Horattas, who anticipates that the numbers have increased with the expansion of the program. Overall, the hospital also saw a 90 percent decrease in opioid administration for those patients using the ERAS protocols who did require some morphine during their stay, he said.

"The patients were easy to convince," said Horattas. "It was tough to convince the other surgeons, anesthesiologists and nurses because it challenged their typical teachings." After they saw results, "we have a great team that works together."

Patient satisfied

Pat Clemas, 70, of Hudson, felt so good after she was released from Akron General following her colorectal surgery that she went to the store with her husband two days later to pick up her Tylenol.

"I didn't feel I needed anything. I felt clearheaded and didn't feel cloudy," said Clemas, who is also no novice to surgery. She has had three Caesarean sections, a hysterectomy, surgery to remove a hernia, two knee-replacement surgeries and three rotator-cuff surgeries.

At Summa, a little more than 50 percent of surgeries now get no narcotics before or during surgery, Mark said. About one-third of Summa patients continue to get no narcotics after surgery.

"The benefit to the patient is immense. The majority of our complications come from narcotics and if we have virtually no pain or very low pain and no narcotics, it's a win-win for the hospital and for everybody," he said.

About 20 percent of patients get no narcotics during their hospital stay and as they go home, Mark said.

Weapon in drug fight

Both Horattas and Mark said their hospitals did not adopt the ERAS protocols because of the opioid epidemic, but recognize the approach helps eliminate the potential for addiction by patients and reduces the amount of unused narcotics in medicine cabinets, which may get used by others.

"Akron is ground zero," Mark said.

The state of Ohio earlier this year also implemented new limits and rules for physicians on opiate prescriptions for acute pain.

Jerry Craig, executive director of the Summit County Alcohol, Drug Addiction and Mental Health Services Board, said he's pleased to hear both local hospital systems are using methods to reduce or eliminate narcotic use in surgical procedures.

The ADM board often suggests that patients ask their doctors for opioid-alternatives.

"We have so many people who are in recovery who fear going under the knife because they fear returning to their addiction. If there's an alternative, it gives them some peace of mind," he said, adding that he recently spoke to a woman who needed a hysterectomy, but was worried about getting addicted to narcotics again from the pain pills.

"It's neat to see that our hospital systems are looking at other creative ways of managing pain," Craig said. "Certainly it's for the right reasons, not just for the opioid epidemic, but because it's the right thing to do."

Betty Lin-Fisher can be reached at 330-996-3724 or blinfisher@thebeaconjournal.com. Follow her @blinfisherABJ on Twitter.

"The patients were easy to convince. It was tough to convince the other surgeons, anesthesiologists and nurses because it challenged their typical teachings."

Mark Horattas

chairman of surgery

at Akron General