New Strategy Almost Halves Opioid Use in Surgical Cancer Patients

A new approach almost halved the use of opioid analgesics in surgical oncology patients without increasing their pain or anxiety.

The two-prong approach included maximizing the use of over-the-counter nonopioid therapies and changing the nature of postsurgery discussions with patients. The result was a 46% reduction in opioid use.

These findings will be presented at the American Society of Clinical Oncology's (ASCO's) upcoming Quality Care Symposium.

"While opioids can be an effective pain management tool for cancer patients, there is a risk of addiction, particularly for people who have recently undergone surgery," said lead author Kerri Stevenson, NP, Stanford Health Care, California, in an ASCO press release.

"We found that when you have conversations with patients about pain control, including nonopioid therapies available and the potential risks associated with opioids, they appreciate being involved in their own care and, subsequently, have a reduced need for opioid medications," she said.

Opioid overuse and misuse have become a top public health concern. Recent data suggest that the situation is getting worse rather than improving, as reported by Medscape Medical News. In 2016, more than 40,000 Americans died from opioid overdose. For many individuals, the first encounter with opioids comes when opioids are prescribed for acute pain management following surgery. An estimated 6% of patients who are not regular users of opioids become newly addicted to these medications post surgery. One recent study found that 10% of cancer patients who underwent curative surgery were still filling opioid prescriptions 1 year after the procedure.

Use Reduced by 46%

In the latest study, Stevenson and her colleagues aimed to reduce reliance on opioid medications in managing postoperative pain by 50%, from a baseline morphine equivalent daily dose (MEDD) of 95.1 to a target MEDD of 47.5.

The authors retrospectively reviewed daily opioid use, pain scores, and anxiety scores for inpatients recovering from surgery for urologic cancers at a high-volume surgical department during a 4-month period. They then used these data to design a "two-pillared" strategy.

The first pillar was focused on developing care pathways for postoperative pain control utilizing nonopioid medications and therapies as first line. This included designing opioid-sparing pain regimens, using varying combinations of acetaminophen, ketorolac, gabapentin, and local anesthetics, and identifying key drivers that were needed to reliably decrease excess opioid use. Providers and nurses were educated about the availability and efficacy of the treatment plans, and although patients were still prescribed opioids, prescribing was at lower doses, and dosing was only escalated if necessary.

The second pillar involved changing postoperative conversations with patients. For example, instead of nurses routinely asking patients whether they needed pain medication (referring to opioids), they instead discussed the current nonopioid medications patients were receiving for pain, along with frequency and dosage, and asked whether this was sufficient. Potential side effects of opioids were also discussed with the patients.

A total of 443 surgical patients were included in the cohort. During the study period, the median opioid use per patient dropped by 46%, from 95.1 to 51.5 MEDD. The decrease in opioid use was observed across multiple procedures.

Importantly, there was no increase in 24- or 48-hour postoperative pain scores associated with the use of opioid-minimizing pathways.

The authors also noted that there were no changes in anxiety scores 24 or 48 hours after surgery.

Experts Weigh In

"New approaches for using appropriate amounts of opioids are crucial now, given the increased public attention given the opioid crisis," commented William Dale, MD, PhD, chair, Supportive Care Medicine, the City of Hope, Duarte, California. "There has been tension in the cancer world about this, and we don't want to cut off the ability for patients to get pain relief. So the question is, how do we go about optimizing the use of opioids while minimizing the risk?"

There has been tension in the cancer world about this. Dr William Dale

The patient cohort used in this study was an "interesting population" in that the patients were completely opioid naive, Dale commented to Medscape Medical News. "This kind of program shows that it can be done through the use of other types of medications and discussions with providers," he said.

One caveat is that alternate medications also have a risk/benefit profile and may have their own side effects. "It's a matter of customizing the options and not just eliminating one or another," he said. "There are multidisciplinary methods of managing pain, and opioids don't have to be used for everyone and in every situation. The bottom line is to evaluate the risk and if they are needed, to use them in a thoughtful way."

Another expert who was contacted for comment noted that these results are useful in two ways. "One is that we do know that a small percentage of patients will end up addicted to opioids," said Michael S. Sabel, MD, FACS, associate professor of surgery and chief of surgical oncology, the University of Michigan, Ann Arbor. "And we see here is that it is not always necessary to give patients a large amount of opioids."

The second is that reducing opioid use also keeps the drugs out of the community, he explained. Even though there are many sources and ways for people to obtain opioids, prescriptions that patients fill and then end up not using can inadvertently fall into the wrong hands.

"We don't want to reduce opioids and have patients in pain," Sabel said. "But this study shows that use was reduced almost by half, and so that lowers the risk of addiction and reduces the number of pills out in the community."

The interventions used in this study can also help guide patients once they return home. "If you can decrease use in the hospital, then it is likely use will be decreased once the patient is discharged," he added.

No source of funding for the study was disclosed. Coauthor Jay Bakul Shah, MD, has a consulting or advisory role with Pacira Pharmaceuticals.

Quality Care Symposium (QCS) 2018. Abstract 269, to be presented September 28, 2018.

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