术后过量处方阿片类药物使用导致持久性阿片类药物使用以及容易滥用和转售的多余药物。采用风险分层的胰腺切除手术临床路径（RSPCP）的学习型健康系统模型可能会导致住院和出院期间阿片类药物用量的减少。本研究旨在分析两次迭代更新后的RSPCP在住院和出院期间阿片类药物用量上的结果。该队列研究纳入了在一个城市的综合癌症中心接受胰腺切除手术的832例成年连续患者，时间跨度为2016年10月至2022年4月，共包括3个顺序病例组（版本[V]1，2016年10月1日至2019年1月31日，n=363；V2，2019年2月1日至2020年10月31日，n=229；V3，2020年11月1日至2022年4月30日，n=240）。在V1路径确定基线并减少住院天数（n=363）后，V2更新了患者和外科医生教育手册，限制了静脉内阿片类药物的使用，并建议使用三种药物（对乙酰氨基酚、塞来昔布、甲氧巴胺）的非阿片类药物组合，同时采用5倍系数（最后24小时口服吗啡当量[OME]乘以5）来计算出院用量。第三个版本的路径（n=240）要求在恢复室中默认使用非阿片类药物组合，并在术后第一天计划转换为口服药物。使用非参数检验和趋势分析比较了三个RSPCP在住院和出院期间OME方面的阿片类药物用量。共有832名连续患者（年龄的中位数[IQR]为65[56-72]岁；女性410名[49.3%]，男性422名[50.7%]）接受了541例胰头十二指肠切除术、285例腺体尾切除术和6例其它腺体切除术。早期非阿片类药物组合的使用在V1（对乙酰氨基酚，320例患者[88.2%]；塞来昔布或抗炎药，98例患者[27.0%]；甲氧巴胺，267例患者[73.6%]）到V3（236例患者[98.3%]，163例患者[67.9%]，238例患者[99.2%]）期间增加，分别为P<0.001。住院期间的总OME从V1的中位数290毫克（IQR，157-468毫克）减少到V2的184毫克（IQR，103-311毫克），再减少到V3的129毫克（IQR，75-206毫克），P<0.001。出院期间的OME从V1的中位数150毫克（IQR，100-225毫克）减少到V2的25毫克（IQR，0-100毫克），再减少到V3的0毫克（IQR，0-50毫克），P<0.001。出院时未使用阿片类药物的患者比例从V1的7.2%（363例患者中的26例）增加到V3的52.5%（240例患者中的126例），P<0.001，其中V3中187例（77.9%）出院时阿片类药物用量为50毫克或更低。各组中的中位疼痛评分始终保持在3或更低水平，出院后无需续方的要求也没有差异。将开放手术和微创手术病例进行亚组分析后，两组结果相似。在这个队列研究中，总住院期间的中位OME减少了一半，出院期间的中位OME减少到零，这与使用学习型健康系统模型迭代减少阿片类药物的方法相吻合，并且可以被其他医院自由采用。这些研究结果表明，胰腺切除术和其他重大癌症手术后无阿片类药物出院是现实和可行的，使用这种无成本的蓝图。

Postoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume.To analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes.This cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version [V] 1, October 1, 2016, to January 31, 2019 [n = 363]; V2, February 1, 2019, to October 31, 2020 [n = 229]; V3, November 1, 2020, to April 30, 2022 [n = 240]).After V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) to calculate discharge volume. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1.Inpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses.A total of 832 consecutive patients (median [IQR] age, 65 [56-72] years; 410 female [49.3%] and 422 male [50.7%]) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients [88.2%]; celecoxib or anti-inflammatory, 98 patients [27.0%]; methocarbamol, 267 patients [73.6%]) to V3 (236 patients [98.3%], 163 patients [67.9%], and 238 patients [99.2%], respectively; P < .001). Total inpatient OME decreased from a median 290 mg (IQR, 157-468 mg) in V1 to 184 mg (IQR, 103-311 mg) in V2 to 129 mg (IQR, 75-206 mg) in V3 (P < .001). Discharge OME decreased from a median 150 mg (IQR, 100-225 mg) in V1 to 25 mg (IQR, 0-100 mg) in V2 to 0 mg (IQR, 0-50 mg) in V3 (P < .001). The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 (P < .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups.In this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.