OCTOBER 4, 2023
Data published in JAMA Surgery indicate that a pain management strategy, risk-stratified pancreatectomy clinical pathways (RSPCP), significantly reduces inpatient and outpatient use of opioids following cancer surgery, thus decreasing the risk for opioid misuse and diversion.
“Through a multimodal pain management regimen that includes patient/provider education, limiting IV medications, actively weaning opioids while still inpatient and using a discharge opioid volume calculator, you can
Data published in JAMA Surgery indicate that a pain management strategy, risk-stratified pancreatectomy clinical pathways (RSPCP), significantly reduces inpatient and outpatient use of opioids following cancer surgery, thus decreasing the risk for opioid misuse and diversion.
“Through a multimodal pain management regimen that includes patient/provider education, limiting IV medications, actively weaning opioids while still inpatient and using a discharge opioid volume calculator, you can successfully discharge patients after major cancer surgery with a median of zero opioids,” lead author Ching-Wei D. Tzeng, MD, an associate professor of surgical oncology at The University of Texas MD Anderson Cancer Center, in Houston, told Pain Medicine News.
Researchers included 832 patients with pancreatic cancer who underwent pancreatic resection (JAMA Surg 2023;e234154. doi:10.1001/jamasurg.2023.4154). RSPCP protocols were improved among three cohorts (version 1, October 1, 2016, to January 31, 2019 [n= 363]; version 2, February 1, 2019, to October 31, 2020 [n= 229]; version 3, November 1, 2020, to April 30, 2022 [n= 240]). By using nonparametric testing and trend analyses, the researchers compared inpatient and discharge opioid volume in OME across the 3 RSPCP.
Version 1 established a baseline and reduced length of stay (n= 363). Version 2 (n= 229) updated patient and surgeon education handouts, limited intravenous opioids and suggested a three nonopioid drug combination (acetaminophen, celecoxib and methocarbamol). Version 2 also implemented the five-time multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) in order to calculate discharge volume. The nonopioid drug bundle was required as default in the recovery in version 3 (n= 240) and patients were scheduled to convert to oral medications on postoperative day 1.
In version 1, inpatient opioid volumes were halved from a median of 290 mg to 129 mg in version 3. The percentage of opioid-free discharges increased from 7.2% in version 1 to 52.5% in version 3, with 77.9% of patients discharged with no more than 50 mg oral morphine equivalents in version 3.
Median pain scores on the Likert scale remained less than 3 or lower in all cohorts, and there were no differences recorded in post-discharge refill requests. These results were not affected when a subgroup analysis was performed between patients who underwent open and those who were treated with minimally invasive surgery.
The researchers stated that the implementation of RSPCP would not make zero opioid discharges a standard of care, but rather that “with an iterative quality improvement process, hospitals can reduce the discharge prescription opioids to a meaningfully low level.”
Although the study was limited to patients undergoing pancreatic resection, Tzeng noted that this is a complex and painful operation, and said he hopes RSPCP will be a strategy that is generalizable to other major cancer surgical operations.
—Myles Starr
Tzeng reported no relevant financial disclosures.
