5x-Multiplier Versus 3-Tier Model

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BACKGROUND: Standardized prescribing models can reduce discharge opioid prescriptions and excess pill volumes, mitigating potential opioid dependence and diversion after abdominal operations. This study's objective was to determine which of 2 validated discharge prescribing models resulted in fewer opioids prescribed and consumed after major abdominal surgery. METHODS: This was a pragmatic single-center, phase II randomized clinical trial comparing 2 discharge opioid prescribing models: linear 5x-multiplier algorithm [last 24 h oral morphine equivalents (OME) times 5] versus capped 3-tier model (5/15/30 pills depending on 0/1-29/≥30 mg OME in last 24 h). Adults undergoing open abdominal cancer resections by 25 surgeons (5 specialties) were included. A nonopioid analgesic bundle was used perioperatively and at discharge. Coprimary endpoints were discharge opioid volume and 14-day post-discharge consumption. Secondary endpoints included patient satisfaction and symptom inventory. The power (80%) calculation was performed using the 2-sample t -test to detect a mean difference in OME with 0.05 significance (0.025 per co-primary outcomes). RESULTS: From April to December 2024, 150 patients (52% female; median age 63) were randomized: 73 to 5x-multiplier; 77 to 3-tier model. Operations included hepatectomy (32%), pancreatectomy (29%), nephrectomy (13%), thoracoabdominal sarcoma resection (15%), and ovarian cytoreduction (11%). Median discharge OME was 25 mg (5x-multiplier) versus 75 mg (3-tier, P <0.001), with 44% of 5x-multiplier patients discharged opioid-free (1% in 3-tier). Median post-discharge 14-day opioid consumption was 0 mg (5x-multiplier) versus 10 mg (3-tier, P =0.496). Refill rates were 24% (5x-multiplier) versus 18% (3-tier, P =0.426), consistent with historical rates, with no differences in satisfaction or symptom inventory scores. CONCLUSION: The 5x-multiplier algorithm resulted in fewer prescribed discharge opioids with similar 14-day consumption, refill rates, and satisfaction, compared with a 3-tier model after intra-abdominal cancer surgery.

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