October 12, 1999. Anesthesiologists working with surgeons have developed a patient care protocol that allows men to go home only one day after prostate cancer surgery. They say this does not "push them out the door" or compromise the quality of care in any way. The protocol makes use of an old pain-killing compound, methadone.

The protocol relies on methadone for postoperative pain, says Evelina Worwag, M.D., assistant professor of anesthesiology and critical care medicine at the University of Chicago and director of the acute pain service at Weiss Memorial Hospital.

The protocol marks the first significant use of methadone in the operating room in nearly two decades, Dr. Worwag reported at the annual meeting of the American Society of Anesthesiologists. While methadone is a synthetic narcotic used in the treatment of heroin addiction, its unique properties make it an effective pain reliever in small doses following surgery, she said.

"Most patients want to go home after surgery as long as they're feeling okay," she said. "We wanted to see if we could design a pathway that would allow them to do so." The new clinical pathway shortens hospital stays, lowers costs and benefits patients because it reduces pain, minimizes complications and speeds recovery, Dr. Worwag said.

A major procedure and an exceptionally painful one, radical retropubic prostatectomy, or RRP, typically involves significant blood loss, a three- to five-day hospital stay, several weeks of recovery and an increased risk of complications such as ileus (immobility of the bowel) and blood clots in the legs.
In a study of 252 men who underwent RRP between 1995 and 1999, 75 percent of the methadone protocol group returned home the day after surgery. Additional patients met the researchers' discharge criteria but chose to stay longer. Of the 91 percent of patients who responded to a follow-up survey, 97 percent expressed satisfaction with their care. According to patient reports, only three complications (one headache and two cases of blood clot retention) were "directly related" or "probably related" to the protocol.

The protocol features a creative approach to pain management, using a combination of regional anesthesia, small doses of methadone and a complementary pairing of over-the-counter pain remedies; a focus on having patients walk, exercise and eat soon after surgery; and heavy doses of patient education before and after the procedure.

Regional anesthesia helps patients recover quicker because the technique blocks the transmission of pain signals to the brain. Patients are sedated but remain conscious and pain-free during surgery. They experience less discomfort later because the regional block prevents pain messages from registering in the brain.

Patients received an injection of methadone at the end of surgery. Tried briefly in the 1980s and abandoned as a pain reliever, methadone blocks the receptors of the spinal cord responsible for suffering, Dr. Worwag said. The substance shows promise because it changes patients' emotional response to pain and works well in small doses, reducing the negative side effects often caused by morphine. These side effects include drowsiness, ileus, nausea and slowing of breathing, which increases the risk of pneumonia.

Patients took two common over-the-counter pain medications -- acetaminophen and ibuprofen -- beginning four hours after surgery and continuing after leaving the hospital. The medications work well in tandem, Dr. Worwag said, because acetaminophen is an effective pain reliever and ibuprofen reduces inflammation.

The protocol uses extensive education to involve patients in their own recovery. "If patients know it is actually better for them to begin walking, eating and exercising soon after surgery, they are more likely to do so," Dr. Worwag said. Physical activity stimulates circulation and promotes healing. Eating restores normal bowel function and quickens the patient's return to a normal routine.

The researchers received reports from three patients who had surgery on a Friday, left the hospital Saturday, went out walking Sunday and returned to work Monday. "We don't recommend this, but we were impressed," Dr. Worwag said.