Guideline-Adherent Opioid Dosing Reduces Hospitalization Time in Patients With Acute Cancer Pain

close up of a group of white tablets with an out of focus prescription bottle in the background
The effect of adherence to guideline-recommended pain management on hospital length of stay is investigated.

In patients with cancer pain, receiving guideline-adherent opioid dosing decreased hospital length of stay (LOS), according to results of a study published in the Journal of Pain & Palliative Care Pharmacotherapy.

This single-center, retrospective cohort study evaluated hospital LOS among patients with uncontrolled pain or pain crisis from 2019 to 2020 at Michigan Medicine medical center. All patients had a pain score of 4 or greater (on a scale of 1 to 10) and had received opioids within 24 hours of hospital admission. The center followed the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology: Adult Cancer Pain, Version 1.2020 which recommends for opioid-naïve and opioid tolerant patients to receive an initial 5 to 15 mg or 2 to 5 mg dose of opioids, respectively. Opioid tolerance was defined as receiving 25 mcg/h or more of fentanyl patch, 60 mg or more of oral morphine daily, 30 mg or more of oral oxycodone daily, 8 mg or more of oral hydromorphone daily, or equianalgesic dose. LOS was evaluated on the basis of whether patients received NCCN guideline-adherent care.

Patients received adherent (n=63) or nonadherent (n=32) care. Patients were median age 63 and 60 years, 41% and 41% were men, 65% and 84% had metastatic disease, and 70% and 41% were opioid naïve (P =.008), respectively.

More patients who received adherent care received morphine (67% vs 22%; P <.001) or hydrocodone (5% vs 0%; P <.001) and fewer received hydromorphone (19% vs 53%; P <.001), oxycodone (9% vs 19%; P <.001), or a pain consultation (27% vs 72%; P <.001). Adherent care was associated with lower doses (mean, 12.22 vs 18.66 morphine milligram equivalents [MME]; P <.001).

The median hospital LOS was 3.7 (range, 1-18.93) days for adherent care compared with 5.4 (range, 1.45-19.64) days for nonadherent care (P =.04). Patients who received adherent care had significantly lower lowest pain scores in 24 hours (median, 3 vs 4; P =.04) and they tended to report lower pain scores in 24 hours (mean, 6.2 vs 6.8; P =.052) and had higher analgesia attainment rates (71% vs 53%; P =.077).

In a subgroup analysis which stratified nonadherent care by over-dosing (n=14) and under-dosing (n=18), over-dosing was associated with smaller differences in hospital LOS compared with adherent care (median, 4.5 vs 3.7 days; P =.035) and under-dosing was associated the longest LOS (median, 6.1 vs 3.7 days; P =.0009). Similarly, the difference in lowest pain score in 24 hours was smaller for over-dosing (median, 4 vs 3; P =.035) and greater for under-dosing (median, 4.5 vs 3; P =.025).

Significant predictors for LOS were pain consultation (slope difference, 3.24; P <.001) and opioid tolerance (slope difference, 1.96; P =.033). Pain consultation (odds ratio [OR], 0.14; P <.001) and opioid tolerance (OR, 0.30; P =.007) were also significant predictors for receiving NCCN guideline adherent care.

The major limitation of this study was the small sample size.

This study data indicated to the investigators that providing NCCN guideline-adherent care to patients with acute cancer pain significantly reduced hospital LOS.


Pena JCD, Marshall VD, Smith MA. Impact of NCCN guideline adherence in adult cancer pain on length of stay. J Pain Palliat Care Pharmacother. 2022;36(2):95-102. doi:10.1080/15360288.2022.2066746