5x-Multiplier Versus 3-Tier Model: A Pragmatic Randomized Clinical Trial for Discharge Opioid Prescriptions After Intra-Abdominal Cancer Surgery.

Authors

Brittany C Fields, Timothy E Newhook, Heather A Lillemoe, Anneliese N Hierl, Innocent Rukundo, Jose A Karam, Surena F Matin, Larissa A Meyer, Zhouxuan Li, Wei Qiao, Jean-Nicolas Vauthey, Matthew H G Katz, Ching-Wei D Tzeng, PROMOTE Consortium

Published in

Annals of surgery. Jun 22, 2026. Epub Jun 22, 2026.

Abstract

Standardized prescribing models can reduce discharge opioid prescription 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.
This was a pragmatic single-center, phase II randomized clinical trial comparing 2 discharge opioid prescribing models: linear 5x-multiplier algorithm (last-24hrs 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-24hrs). Adults undergoing open abdominal cancer resections by 25 surgeons (5 specialties) were included. A non-opioid analgesic bundle was used perioperatively and at discharge. Co-primary 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 two-sample t-test to detect a mean difference in OME with 0.05 significance (0.025 per co-primary outcomes).
From April-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 75mg (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 0mg (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.
The 5x-multiplier algorithm resulted in fewer prescribed discharge opioids with similar 14-day consumption, refill rates, and satisfaction, compared to a 3-tier model after intra-abdominal cancer surgery.

PMID:
42322127
Bibliographic data and abstract were imported from PubMed on 20 Jun 2026.

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