Postoperative restrictive opioid protocols reduce long-term opioid use

Research at Roswell Park Comprehensive Cancer Center shows that putting a three-day limit on opioid prescriptions to treat surgical pain after hospital discharge reduces the number of patients who become chronic opioid users without compromising pain relief or recovery. It also reduces the amount of opioids circulating in the community -; a grave concern, given that opioids are implicated in 130 overdose deaths in the U.S. every day.

The study, "Postoperative restrictive opioid protocols and durable changes in opioid prescribing and chronic opioid use," appears in JAMA Oncology. It was led by Emese Zsiros, MD, PhD, the Shashi Lele, MD, Endowed Chair and Director of Research, Department of Gynecologic Oncology.

The study reports the results of an institute-wide quality-improvement protocol in place at Roswell Park for six months, from February to July 2019, which affected 2,051 surgical patients. During that period, providers at the cancer center were advised to prescribe no more than three days' worth of opioids when a patient was discharged after surgery, with individual surgical services creating their own algorithms to comply with the protocol while still providing sufficient pain control for their patients. The protocol has since been adopted as the new standard of care at Roswell Park.

Both clinical providers and patients were educated about the protocol in advance. The Roswell Park Pharmacy Department reported 95% compliance with the new restrictive opioid protocol.

Data collected during the protocol period were compared with data involving 2,017 surgical patients treated over the previous six months. Researchers found that during the pre-protocol period, 3.9 days was the mean duration of opioid prescriptions written at discharge. During the protocol, that number dropped to 1.9 days, with a 45% decrease in the volume of opioids prescribed. In addition, patient requests for refills dropped from 20.9% pre-protocol to 17.9% post-protocol -; a 14% decrease.

Most important, the number of patients who converted to chronic use of opioids after surgery fell in both opioid-naïve cancer patients (from 11.3% pre-protocol to 4.5% post-protocol) and non-cancer patients (from 6.1% pre-protocol to 2.7% post-protocol). Dr. Zsiros and her team relied on New York State's rigorous system of tracking opioid prescriptions, zeroing in on how many new prescriptions the patients filled three months after discharge, when post-surgical pain would no longer be an issue.

Dr. Zsiros notes that data from the Centers for Disease Control and Prevention (CDC) show taking opioids for more than three days elevates the risk of conversion to chronic use. "But we don't really know which patients are at risk," she explains. "Some patients take opioids for a few days and are never able to come off of them. Others don't like how opioids make them feel and become so nauseated that they just don't want to take them."

She adds that New York State has some of the strictest policies in the nation when it comes to prescribing opioids for acute pain, such as pain experienced immediately after surgery. But the state's seven-day prescription limit is substantially longer than the three-day protocol window, after which the risk of habitual use increases.

At the same time, the seven-day limit for treating acute pain does not apply to patients who have a cancer diagnosis.

Current state regulations allow us to prescribe literally unlimited opioids for acute pain, because our patients have a cancer diagnosis. When it comes to end-of-life care and cancer-related pain management, we fully support the use of opioids as necessary; however, many of our patients are opioid-naïve at the time of surgery and are also long-term survivors. Thus, reducing the conversion to chronic opioid use could potentially further extend their lives."

Dr. Emese Zsiros, MD, PhD, the Shashi Lele, MD, Endowed Chair and Director of Research, Department of Gynecologic Oncology

Cancer patients also are exempt from the CDC's updated clinical practice guidelines for prescribing opioids for pain, released in November 2022.

Dr. Zsiros says she hopes the study will lead to substantive changes in pain management after surgery. "Implementing a restrictive protocol across a cancer center is not only feasible but decreases the circulating opioids in the community and the conversion to chronic opioid use among our cancer patients."