*Purpose: Given the association between substance use disorder and risk of post-surgical opioid use disorder, we developed an opioid avoidance pathway (OAP) in adult liver transplant recipients (LTR). This study evaluates post-operative morphine milligram equivalent (MME) use between a historical cohort (HC) and the pilot OAP cohort (OAPC).

*Methods: The HC included LTR from 8/20/2016-1/18/2018, and was managed primarily with opioids alone. The OAPC included LTR from 1/18/2018-9/30/2019. Multiorgan recipients and opioid-tolerant patients were excluded. The OAP was initially offered to LTR who achieved sobriety within 1 year of listing; however, we then expanded to all LTR. At listing, candidates received multidiscplinary education on pain expectations and OAP therapies. Perioperatively, the OAPC received ketamine, incisional ropivacaine, gabapentin, and acetaminophen. Tizanidine or baclofen were added if needed, and rescue opioids were given for unacceptable pain control. Fisher’s exact test or the Fisher-Boschloo test was used for categorical data. Continuous data were compared with a Student’s t-test or Mann-Whitney U test. Statistical significance was set at α=0.05.

*Results: Baseline characteristics between the HC (n=27) and OAPC (n=13) were comparable (Table 1). The OAPC used fewer post-operative MME in the first week post-LT (Figure 1), with a 92% reduction in average MME utilization per day (total MME/total length of stay [LOS]) [median, IQR; 6.8, 0.6-10.5 vs 87.3, 59.5-130.1; p<0.001]. Patient-reported pain scores (0-10 scale) were comparable in the first week post-LT (Figure 1). There was no difference in LOS (days; median, IQR: OAPC: 8, 7-10 vs HC: 6, 6-10; p=0.135). In the OAPC, ketamine was discontinued in 3 patients, 2 for altered mental status and 1 for intraoperative pulmonary hypertension. The OAPC received fewer outpatient MME from discharge to post-operative day 60 (median, IQR: 125, 25-150 vs 270, 0-463; p=0.049).

*Conclusions: An opioid-avoidant strategy in LTR can significantly reduce opioid use while maintaining a similar level of pain control.

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