A prospective feasibility study evaluating the 5x-multiplier to standardize discharge prescriptions in cancer surgery patients

DiPeri, Timothy P.; Newhook, Timothy E.; Day, Ryan; Chiang, Yi‐Ju; Dewhurst, Whitney L.; Arvide, Elsa M.; Bruno, Morgan L.; Scally, Christopher P.; Roland, Christina L.; Katz, Matthew H.G.; Vauthey, Jean‐Nicolas; Chang, George J.; Badgwell, Brian D.; Perrier, Nancy D.; Grubbs, Elizabeth G.; Lee, Jeffrey E.; Tzeng, Ching‐Wei D.

doi:10.1016/j.sopen.2022.04.004

Cited by 6 publications

(6 citation statements)

References 38 publications

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“…Previously, our group demonstrated the feasibility of using the 5×-multiplier in a cohort of patients undergoing liver or pancreas resections . We then expanded the 5×-multiplier to the entire department of surgical oncology in a follow-up prospective study that showed feasibility in multiple types of cancer surgery, regardless of LOS . We demonstrated a progressive, sustained decline in discharge opioid prescriptions that coincided with increasing compliance (89.2% in V3) with the 5×-multiplier guideline, with no reflexive increased refill needs.…”

Section: Discussionmentioning

confidence: 92%

“…The second cohort (V2: February 1, 2019, to October 31, 2020; n = 229) updated patient and surgeon education handouts, standardized intravenous patient-controlled anesthesia (IV-PCA) dosage, suggested (not mandatory) a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle starting on postoperative days (PODs) 0 to 1, and implemented the 5×-multiplier (last 24-hour OME multiplied by 5) to calculate discharge volume . Medications were converted to oral formulations per surgeon perception of tolerance.…”

Section: Methodsmentioning

confidence: 99%

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Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm

Boyev,

Jain,

Newhook

et al. 2023

JAMA Surg

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ImportancePostoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume.ObjectiveTo analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes.Design, Setting, and ParticipantsThis cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version [V] 1, October 1, 2016, to January 31, 2019 [n = 363]; V2, February 1, 2019, to October 31, 2020 [n = 229]; V3, November 1, 2020, to April 30, 2022 [n = 240]).ExposuresAfter V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) to calculate discharge volume. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1.Main Outcomes and MeasuresInpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses.ResultsA total of 832 consecutive patients (median [IQR] age, 65 [56-72] years; 410 female [49.3%] and 422 male [50.7%]) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients [88.2%]; celecoxib or anti-inflammatory, 98 patients [27.0%]; methocarbamol, 267 patients [73.6%]) to V3 (236 patients [98.3%], 163 patients [67.9%], and 238 patients [99.2%], respectively; P &lt; .001). Total inpatient OME decreased from a median 290 mg (IQR, 157-468 mg) in V1 to 184 mg (IQR, 103-311 mg) in V2 to 129 mg (IQR, 75-206 mg) in V3 (P &lt; .001). Discharge OME decreased from a median 150 mg (IQR, 100-225 mg) in V1 to 25 mg (IQR, 0-100 mg) in V2 to 0 mg (IQR, 0-50 mg) in V3 (P &lt; .001). The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 (P &lt; .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups.Conclusions and RelevanceIn this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.

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Section: Discussionmentioning

confidence: 92%

Section: Methodsmentioning

confidence: 99%

Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm

Boyev,

Jain,

Newhook

et al. 2023

JAMA Surg

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“…We found that robotic PD was associated with decreased inpatient opioid use with similar postoperative pain scores. In both robotic PD and open PD groups, we found relatively low opioid usage due to several iterative changes we have made across our Department of Surgical Oncology for postoperative analgesia across disease sites 5,13,14,18–26 . Lower inpatient opioid use then led to reduced discharge prescription volumes overall.…”

Section: Discussionmentioning

confidence: 93%

“…In both robotic PD and open PD groups, we found relatively low opioid usage due to several iterative changes we have made across our Department of Surgical Oncology for postoperative analgesia across disease sites. 5,13,14,[18][19][20][21][22][23][24][25][26] Lower inpatient opioid use then led to reduced discharge prescription volumes overall. On multivariate analysis, the robotic approach, absence of a pancreatic fistula and older age were associated with decreased OME.…”

Section: Discussionmentioning

confidence: 99%

Comparative analysis of opioid use between robotic and open pancreatoduodenectomy

Witt

Hirata

Prakash

et al. 2022

J Hepato Biliary Pancreat

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Background/Purpose: Risk-stratified pancreatectomy clinical pathways using regional anesthesia and multimodality analgesia have decreased overall opioid use, but the additional benefits of robotic surgery in opioid reduction for pancreatoduodenectomy (PD) are unknown. We compared the inpatient opioid use between robotic PD and open PD. Methods: Patients undergoing open PD within a protocol evaluating preincisional regional anesthetic block bundles were compared to consecutively-treated patients undergoing robotic PD identified from a prospectively maintained singleinstitutional database. Clinical characteristics, operative outcomes, pain scores and inpatient oral morphine equivalent (OME) use were compared between patients treated with robotic or open PD. Patients with a history of continuousrelease opioid dependence were excluded. Results: Of 114 total patients, 25 underwent robotic PD and 89 underwent open PD. Intraoperative opioid use was not different (P = .87), nor were cumulative pain scores. Robotic PD patients used significantly fewer OMEs per day on postoperative days 1-4 (P = .039), used fewer total OMEs during hospitalization (robotic: median = 79, IQR 42.5-141; open: median = 126, IQR 61.3-203.8; P = .0036) and were discharged with fewer OMEs (robotic: median = 0, IQR 0-43.8; open: median = 25, IQR 0-75; P = .009) despite a shorter length of stay (robotic: median = 4, open: median = 5, P = .002). Conclusions: Robotic PD patients required fewer inpatient OMEs than open PD while maintaining similar pain scores. A higher percentage of robotic PD patients tapered off of opioids prior to discharge than open surgery patients treated with a standardized opioid reduction protocol despite a shorter length of stay. These results provide a rationale for choosing robotic PD when feasible to minimize opioid use.

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“…A rational way to determine a reasonable amount of opioid pills is to use a multiplier. 28,29 If you look at the patient's use of opioid pills over the 48 hours before discharge, you can estimate the average daily number of pills a patient might require after discharge. No evidence-based multiplier exists for the trauma population, but at our center, we provide a week's worth of opioid pills, meaning a multiplier of 7.…”

Section: Opioid Prescribing At Dischargementioning

confidence: 99%

Acute pain management after trauma: What you need to know

Klugh,

Harvin

2023

J Trauma Acute Care Surg

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Effective acute pain control is mandatory after injury. Opioids continue to be a pillar acute pain management of strategies despite not being as effective as some non-narcotic alternatives. An acute pain management strategy after trauma should be thoughtful, effective, and responsible. A thoughtful approach includes managing a patient’s expectations for acute pain control and ensuring interventions purposefully and rationally affect the domain of pain which is uncontrolled. An effective pain management strategy includes a multi-modal approach using acetaminophen, non-steroidal anti-inflammatory drugs, and regional anesthesia. A responsible acute pain management approach includes knowing the relative strengths of the opioids prescribed and standardized approach to opioid prescribing at discharge to minimize diversion. Acute pain management is quite understudied and future considerations include a reliable, objective measurement of pain and the evaluation of non-medication acute pain interventions.

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A prospective feasibility study evaluating the 5x-multiplier to standardize discharge prescriptions in cancer surgery patients

Cited by 6 publications

References 38 publications

Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm

Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm

Comparative analysis of opioid use between robotic and open pancreatoduodenectomy

Acute pain management after trauma: What you need to know

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