Opioid Avoidance in Liver Transplant Recipients: Reduction in Postoperative Opioid Use Through a Multidisciplinary Multimodal Approach

Abstract

The prevalence of substance use disorder in the liver transplantation (LT) population makes postoperative pain management challenging. We report our initial experience with a novel, comprehensive, multidisciplinary opioid avoidance pathway in 13 LT recipients between January 2018 and September 2019. Patients received comprehensive pre‐LT education on postoperative opioid avoidance by the surgeon, pharmacist, and psychologist at the time of listing. Immediately after LT, patients received a continuous incisional ropivacaine infusion, ketamine, acetaminophen, and gabapentin as standard nonopioid medications; rescue opioids were used as needed. We compared outcomes with a historical cohort of 27 LT recipients transplanted between August 2016 and January 2018 managed primarily with opioids. On average, opioid avoidance patients used 92% fewer median (interquartile range [IQR]) morphine milligram equivalents (MMEs) versus the historical cohort (7 [1‐11] versus 87 [60‐130] MME; P < 0.001) per postoperative day over a similar length of stay (8 [7‐10] versus 6 [6‐10] days; P = 0.14). Fewer outpatient MMEs were prescribed within the first 60 days after LT in the opioid avoidance group versus the historical cohort: 125 (25‐150) versus 270 (0‐463) MME (P = 0.05). This proof‐of‐concept study outlines the potential to profoundly reduce opioid utilization in the LT population using a comprehensive multidisciplinary approach.

2020 Clinical Update in Liver Transplantation

“…61 Even with limited data, Kutzler et al sought to investigate the development of a comprehensive multidisciplinary opioid avoidance pathway (OAP) for LT recipients at their institution. 62 The OAP was developed by a multidisciplinary team of health care specialists and offered to all liver transplant recipients regardless of substance use history. Table 3 illustrates the general pathway for patients from pre-transplant to their post-transplant care.…”

Perioperative management of adult living donor liver transplantation: Part 1 – recipients

“…Preoperatively, LT candidates often present with chronic pain (50-80% of cirrhosis patients take opioids), anxiety, depression, and psychosocial issues. 98 Given the nonemergent nature of LDLTs, the multidisciplinary transplant care team has an opportunity to optimize these recipients' conditions and facilitate their understanding of post-LDLT recovery processes. This is critical for the successful management of perioperative pain.…”

“…This is critical for the successful management of perioperative pain. 98 Intraoperatively, opioid-sparing protocols have been implemented using ketamine, lidocaine, magnesium, dexmedetomidine, midazolam, and steroids. 98 The timing and duration of these medications must be carefully considered as they relate to liver function and the potential for oversedation.…”

Opioid Avoidance After Liver Transplantation: The Ever‐Shifting Pain Management Paradigm

“…In this issue, Kutzler et al ( 8 ) present a proof‐of‐concept study demonstrating that postoperative transplant pain can be managed with minimal opioid analgesia. Notably, this intervention started with a pretransplant, multidisciplinary pain management education program that included a pharmacist, mental health provider, and surgeon.…”

“…The work presented by Kutzler et al ( 8 ) represents another step toward opioid‐sparing analgesia in a population of patients at risk for adverse opioid‐related events. Implementing these changes more broadly, however, will require further research to establish the evidence base for alternative approaches, caregiver buy‐in, and active implementation support.…”