Learning health system model tied to opioid-free discharge after pancreatectomy: JAMA

In the Postoperative phase, when opioids are overprescribed, it leads to persistent opioid use. The excess pills increase the risk of misuse and diversion. Researchers say that learning the health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) causes a reduction in inpatient and discharge opioid volume. In the present cohort study, the team analyzed the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes.

Eight hundred thirty-two consecutive adult patients at an urban, comprehensive cancer centre underwent pancreatic resection between October 2016 and April 2022.

This comprised three sequential pathway cohorts (version 1, 2 and 3 with n=363, 229 and 240, respectively).

After V1 of the pathway established a baseline and reduced length of stay, V2 updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug nonopioid bundle including acetaminophen, celecoxib, methocarbamol and implemented the 5×-multiplier to calculate discharge volume. Pathway version 3 required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1.

The key results of the study are:

• These 832 patients had a median age of 65 years.
• The number of females and males was 410 and 422 respectively, constituting 49.3% and 50.7 % respectively.
• These underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and six other pancreatectomies.
• Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients; celecoxib or anti-inflammatory, 98 patients; methocarbamol, 267 patients, to V3 (236 patients, 163 patients and 238 patients, respectively.
• There was a decrease in the total inpatient OME from a median of 290 mg in V1 to 184 mg in V2 to 129 mg in V3.
• Discharge OME decreased from a median of 150 mg in V1 to 25 mg in V2 to 0 mg in V3.
• The percentage of patients discharged opioid free increased from 7.2% in V1 to 52.5% in V3, with 187 of 240 in V3 discharged with 50 mg OME or less.
• Median pain scores remained three or lower in all cohorts, with no differences in postdischarge refill requests.
• As per subgroup analysis separating open and minimally invasive surgical cases, both groups had similar results.

Our study found that 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.

Further reading:

https://jamanetwork.com/journals/jamasurgery/article-abstract/2809262