Utilization and evolving prescribing practice of opioid and non‐opioid analgesics in patients undergoing lymphadenectomy for cutaneous malignancy

Witt, Russell G.; Cope, Brandon; Chiang, Yi‐Ju; Newhook, Timothy E.; Lillemoe, Heather A.; Tzeng, Ching‐Wei D.; Chen, Iris B.; Fisher, Sarah B.; Lucci, Anthony; Wargo, Jennifer A.; Lee, Jeffrey E.; Ross, Merrick I.; Gershenwald, Jeffrey E.; Robinson, Justine; Keung, Emily Z.

doi:10.1002/jso.26768

Cited by 3 publications

(3 citation statements)

References 35 publications

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“…12,13 A follow-up study 1 year later found that the educational interventions were associated with decreased inpatient and discharge opioid prescribing. 19,37 While other institutions have shown similar first-pass gains with opioid reduction programs, 38 this study is the first to our knowledge to show an association with sustained reductions in opioid consumption and dissemination over 2 iterative revisions of established pathways, resulting in attainment of a previously unrealistic goal of opioid-free discharge after pancreatic resection.…”

Section: Discussionmentioning

confidence: 67%

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: 67%

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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Postoperative pain scores and opioid use after standard bupivacaine vs. liposomal bupivacaine regional blocks for abdominal cancer surgery: A propensity score matched study

Boyev,

Popat,

Gottumukkala

et al. 2024

The American Journal of Surgery

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Utilization and evolving prescribing practice of opioid and non‐opioid analgesics in patients undergoing lymphadenectomy for cutaneous malignancy

Cited by 3 publications

References 35 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

Postoperative pain scores and opioid use after standard bupivacaine vs. liposomal bupivacaine regional blocks for abdominal cancer surgery: A propensity score matched study

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