Opioid-Free Discharge After Pancreatic Resection Can Be Achieved, Study Shows

Inpatient oral morphine equivalents (OMEs) were halved and median discharge OMEs were reduced to zero for pancreatic resection patients at a single center after two iterative updates of a risk-stratified pancreatectomy clinical pathway.

Three sequential versions of the pathway were used over approximately 6 years. Total inpatient OMEs decreased from a median 290 mg in version 1 of the pathway to 184 mg in version 2, then dropped to 129 mg in version 3 (P<0.001), reported Ching-Wei Tzeng, MD, of the University of Texas MD Anderson Cancer Center in Houston, and colleagues.

Discharge OMEs decreased from a median 150 mg in version 1 to 25 mg in version 2, falling to 0 mg in version 3 (P<0.001), the researchers wrote in JAMA Surgery.

The percentage of opioid-free discharges increased from 7.2% in version 1 to 52.5% in version 3, with 77.9% of patients in version 3 discharged with 50 mg OME or less. Neither pain scores nor post-discharge refill requests increased.

The findings offer a blueprint for iterative opioid reduction after pancreatectomy and other major cancer operations that can be freely adapted by other hospitals, Tzeng and co-authors said.

Since the CDC changed its opioid prescribing guidelines in 2016, clinicians and healthcare systems in the U.S. have made efforts to reduce the amount of opioids dispensed to patients. The CDC guidance has undergone further revisions, but still asks prescribers to consider non-opioid approaches to managing pain.

While only 10% of opioid prescriptions are written by surgeons, initial exposures can lead to persistent use or to diversion to family or community members, Tzeng and colleagues noted.

“Most people, including providers and patients, know that we shouldn’t use a lot of opioids, but it does take a little bit of work and agreement on a protocol to do so,” Tzeng told MedPage Today.

Pancreatic resection is considered a very painful surgery and the key was that patients were “still getting pain medicine, just not the opioid pain medicine,” Tzeng said.

“If we went back to 2017, people would think we’d be crazy to do this,” he pointed out. “But now, people are having surgery and going home with non-opioids, and not on anything at all.”

The study included 832 adult patients who underwent pancreatic resection at MD Anderson Cancer Center between October 2016 and April 2022 under one of three sequential pathways:

• Version 1 (2016-2019) established baseline data, reduced length of stay, and included regional blocks, acetaminophen, and the surgeon’s preference of nonsteroidal anti-inflammatory drugs (NSAIDs; celecoxib) and muscle relaxants (methocarbamol). Partway through this phase, the center implemented a department-wide opioid reduction education program and amended the pathway.
• Version 2 (2019-202o) updated educational handouts, limited intravenous opioids, suggested a three-drug non-opioid bundle using the same drugs as version 1, and implemented a tool to calculate discharge opioid volume (five times the last 24-hour OME). This version coincided with a regional nerve block trial that enrolled patients from March 2019 through November 2020.
• Version 3 (2020-2022) required the three-drug non-opioid bundle as default starting in the recovery room and converted patients to oral medications on postoperative day 1. A 1-day reduction in length of stay was targeted.

Versions 1, 2, and 3 included 363, 229, and 240 patients, respectively. Median age was 65 years, 49.3% were female, and 73.4% were white. Most patients (65%) had pancreatoduodenectomies and 34% had distal pancreatectomies.

Pain was assessed on a numeric scale from 1 to 10, with higher scores indicating more severe pain. Median pain scores throughout hospitalization were less than or equal to 3 in all groups. Median length of stay went from 6 days in version 1 to 5 days in version 3. Most patients did not require opioid refills after discharge, and few continued postoperative opioid use.

A subgroup analysis comparing patients with open and minimally invasive resection showed similar results in both groups.

“Instituting ERAS [early recovery after surgery] protocols is clearly the standard; however, what is equally apparent is that they need to be constantly revised and improved,” observed Melissa Hogg, MD, MS, of NorthShore University Health System in Evanston, Illinois, in an accompanying editorial.

The researchers “should be applauded for continuing to strive to make things better, not just for cancer treatment, not just for perioperative outcomes, but for a holistic approach to patients’ wellness and health,” Hogg wrote. “Their study inspired me to update our institution’s ERAS protocol to reduce and eliminate opioid prescriptions.”

The study had several limitations, including its single-center design, Tzeng and colleagues acknowledged. Though pain scores were assessed, patient feedback about pain control expectations or post-operative quality of life was not. In addition, records of opioid prescriptions were limited to the hospital system.

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