More Evidence to Support Restrictive Opioid Prescribing After Cancer Surgery

A restrictive postoperative opioid prescribing policy for patients with cancer led to a 50% reduction in opioid prescription days and an even larger decrease in the rate of conversion to chronic opioid use, a prospective cohort study showed.

Mean opioid prescription days decreased from 3.9 days before policy implementation to 1.9 days in the first 6 months afterward, accompanied by a 45% decrease in prescribed opioids after surgery. Patient requests for new opioid prescriptions also declined significantly.

Conversion to chronic opioid use occurred in 11.3% of patients prior to the policy versus 4.5% afterward, reported Emese Zsiros, MD, PhD, of Roswell Park Comprehensive Cancer Center in Buffalo, New York, and co-authors in JAMA Oncology. The findings set the stage for future investigations of opioids' impact on cancer outcomes.

"We really don't know what is the effect of opioids on cancer outcomes," Zsiros told MedPage Today. "There are some data suggesting that opioids can fuel cancer progression, can lead to premature death. Many of our patients are long-term survivors, so this is really a big concern [whether] a patient becomes a chronic opioid user because they had surgery at the beginning of their cancer treatment. Are we really shortening their life expectancy by giving them too much and converting them to chronic users?"

"I think our future research is really going to focus on the impact of opioids on cancer outcomes, really trying to look at what is happening to those patients who are chronically using opioids compared to an opioid-naive cohort," she added.

Patient-reported outcomes will be described in a future publication, but Zsiros said patients treated before and after implementation of the prescribing policy reported similar levels of satisfaction with their care.

The findings came from an analysis involving 4,068 patients with cancer treated surgically at Roswell Park from Aug. 1, 2018 to July 31, 2019. The study represented an expansion of a previously reported pilot investigation limited to patients who had surgery for gynecologic cancers. The pilot study showed an 89% reduction in postoperative opioid prescriptions and few complaints from patients.

The current study involved all surgical services at the cancer center. The restrictive protocol limited postoperative opioid prescriptions to a maximum of 3 days after discharge. The policy included standardized patient education about opioids and opioid prescribing. The primary outcome was compliance with the protocol in each surgical service, mean number of prescription days and refill requests, type of opioid prescribed, and rate of conversion to chronic opioid use (determined by a state-run opioid prescription program).

The study population comprised 2,017 patients treated in the 6 months prior to implementation of the prescription policy (Aug. 1, 2018 to Jan. 31, 2019) and 2,051 treated after the policy went into effect (Feb. 1 to July 31, 2019). Mean patient age was 61, and women accounted for 62.1% of the total.

The most common procedures in both cohorts involved breast, gastrointestinal, head and neck, and thoracic cancers (>80%). Two-thirds of operations were open procedures, and surgical complexity had fairly even distribution between major and minor. Length of stay averaged 2.5 days during both study periods, and 81-82% of patients in both groups had cancer diagnoses confirmed by surgery.

Overall, compliance with the prescription protocol was 95%. The decrease in prescription days achieved statistical significance (P<0.001), and the magnitude of decrease was similar across the different surgical services. Continued follow-up into the fourth quarter of 2020 showed that the change in opioid prescribing practices remained stable after 6 months.

Mean prescribed opioids after surgery (in morphine milligram equivalents [MME]) decreased from 157 prior to the policy to 83.54 after implementation (P<0.001). Mean MME continued to decline in the post-study period, reaching a low of 43.01 during the subsequent year. The proportion of patients requesting refills decreased from 20.9% to 17.9% (P=0.02), despite the fact that the post-policy cohort received fewer opioids after surgery.

About 20% of patients with cancer diagnoses in the pre-policy cohort met criteria for opioid exposure prior to surgery, as did 16.5% of the patients in the post-policy period. About 15-16% of patients with noncancer diagnoses also had prior opioid exposure. Zsiros said patients with prior exposure to opioids were more likely to convert to chronic opioid use after surgery, and the trend was evident in patients with and without cancer diagnoses.

Zsiros emphasized the study focused only on patients undergoing surgery for cancer, not patients at end of life with terminal cancer.

"Every time we have published on opioids, I have learned that it is a bit of a controversial topic," she said. "I anticipate that we are going to get a little bit of negative media as a result. In the manuscript I think we spend a lot of time in the discussion section saying that if someone needs end-of-life care or needs opioids, our priority is to make sure that they have it."

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