Clinical care pathway updates greatly reduce opioid use after pancreatic cancer surgery
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Researchers at The University of Texas MD Anderson Cancer Center have made improvements to hospital care pathways that reduced opioid use by 50% after pancreatic cancer surgery.
The cohort study — published in JAMA Surgery — evaluated 832 patients undergoing pancreatic resection. Investigators assessed the effects of incremental modifications to postsurgical procedures on the use of opioids during hospitalization and at the time of discharge.
“Recent studies from other institutions suggest that opioid dependence is as high as 10% to 15% after cancer surgery, and potentially higher in patients who need chemotherapy after their surgery,” Ching-Wei Tzeng, MD, associate professor of surgical oncology at MD Anderson Cancer Center, told Healio. “Pancreatic cancer — because of its location — is often painful, and the traditional thought has been that these patients will never get off pain medications.”
Tzeng spoke with Healio about the importance of relieving pain in this patient population and how the modifications in his team’s study yielded a reduction in opioid use.
Healio: How is pain after pancreatic cancer surgery currently managed?
Tzeng: There is no standard in the United States. Often, patients will get either an epidural or nerve block to help with pain upon waking up from anesthesia. Then they get an IV-patient-controlled analgesia (PCA) button controlling injections of opioids like morphine or hydromorphone. They may or may not get nonopioids like acetaminophen, NSAIDs and muscle relaxers. They are transitioned to oral opioids as they start eating. Then they are discharged on whatever a provider “thinks” the patient needs based on their personal assessment.
Healio: What modifications to postoperative pain relief procedures did you evaluate in your study? How did their design avoid opioid dependence?
Tzeng: There are four main pillars, with the last one being perhaps the easiest intervention for others to adopt. In pillar one, we give handouts to patients in clinic and at discharge explaining the various nonopioids we give them and recommend stopping opioids first. In pillar two, we limit IV-PCA and heavy use of IV meds. We found that 75% of opioids were used in the first 48 hours with high-dose IV meds. In pillar three, we actively wean down the opioids with the help of that nonopioid bundle that starts in the recovery room. In pillar four, we use the “5×-multiplier,” which we created to personalize how much opioid volume is given at discharge. We take the number of pills you took in the last 24 hours and multiply by 5. This gets rid of the usual problem if simply prescribing a standard one-size-fits-all volume like 30, 40, or 50 pills. This fourth pillar really limits the overprescription of opioids, which can end up sitting at the house, with danger to the patient and their family.
Healio: How did these modified pain approaches perform, both in terms of reducing pain and reducing opioid use?
Tzeng: There was no increase in pain scores or refills. We reduced our inpatient opioid use by 50% and cut down our outpatient prescriptions from more than 40 pills per patient before 2018 to now a median of zero, with 75% of patients needing less than 10 pills at discharge.
Healio: What is the next step in this research?
Tzeng: We are setting up a randomized trial comparing this 5×-multiplier to another well-published system that uses three tiers to prescribe 5, 15 or 30 pills at discharge based on the patient’s last 24 hours. But the theme here is that the best protocol, in my opinion, is to base your decision for a discharge opioid prescription on the last 24 hours of use. We must stop prescribing a one-size-fits-all approach based on the patient’s age, sex, race or operation. We need to stop that bias.
Healio: What do you hope will be the long-term clinical implications of your findings? Tzeng: My hope is that we can optimize a patient’s recovery in the short-term, with less drowsiness and constipation from opioids, and prevent a secondary complication of surgery — opioids misused by the patient and/or their family or community.
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For more information:
Ching-Wei Tzeng, MD, can be reached at MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1484, Houston, TX 77030; email: cdtzeng@mdanderson.org.
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