The 5x-multiplier algorithm reduces opioids prescribed at discharge

1. The 5x-multiplier approach reduced opioid prescribing at discharge compared to the 3-tier model after intra-abdominal cancer surgery.

2. Fewer prescribed discharge opioids in the 5x-multiplier group did not worsen 14-day opioid consumption, refill rates, or patient satisfaction.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Postoperative opioid prescribing requires a balanced approach to adequately address pain while minimizing unintended outcomes. Several standardized approaches exist for the management of opioid prescriptions at hospital discharge. This randomized clinical trial featured an intervention group according to the 5x-multiplier prescribing strategy, which calculated the discharge opioid prescription by multiplying the opioid units required during the last 24 hours of hospitalization by five. In comparison, the 3-tier control group received 5, 15, or 30 pills according to the range of opioid equivalents required during the final day of hospitalization. The trial included adults in the postoperative period after abdominal cancer surgery, and both groups were treated according to a multimodal pain control regimen inclusive of nonopioid methods. Patients assigned to the 5x-multiplier received substantially fewer opioids at discharge and were more often able to leave the hospital without an opioid prescription compared to the 3-tier group. This reduction in initial prescribing did not result in greater opioid use at two weeks following discharge. Rates of opioid refills, patient satisfaction, and postoperative symptom burden were also comparable between groups. The randomized design and direct comparison of two established prescribing strategies were major strengths of this study, as was the inclusion of several different abdominal oncologic procedures. However, the simultaneous incorporation of a multimodal nonopioid pain regimen in this single-center study complicates the interpretation of observed differences between groups. In addition, symptom assessments were obtained at specific follow-up points and may have been affected by other aspects of patients’ cancer care.

Click to read the study in Annals of Surgery

Relevant Reading: A prospective feasibility study evaluating the 5x-multiplier to standardize discharge prescriptions in cancer surgery patients

In-Depth [randomized controlled trial]: This pragmatic, single-center phase II randomized trial enrolled 150 adults undergoing open abdominal cancer resections. Patients were assigned to either a 5x-multiplier opioid prescribing strategy (n = 73) or a 3-tier approach (n = 77). The primary outcomes were the oral morphine equivalents prescribed at discharge and opioid consumption during the first 14 days after hospital discharge. Secondary outcomes included refill requests, complications, satisfaction, and patient-reported symptoms. Patients in the 5x group were prescribed significantly fewer opioids, with a median oral morphine equivalent dose at discharge of 25 mg compared to 75 mg in the 3-tier group (P < .001). Additionally, 43.8% of patients in the 5x group did not require any opioid prescription at discharge, compared to only 1.3% in the 3-tier group (P < .001). Despite the lower initial prescriptions, opioid consumption over the subsequent 14 days did not differ significantly between groups (P = .496). Opioid refill requests were similar between groups, occurring in 24.7% of patients in the 5x group and 18.2% in the 3-tier arm (P = .333). Patient satisfaction and postoperative symptom scores were likewise comparable, with no significant differences in symptom burden at either 14 days or three months. Overall, the 5x strategy substantially reduced the quantity of opioids prescribed at discharge without negatively impacting subsequent opioid use, refill requirements, or patient-reported symptoms.

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