A Multicentre Cluster Randomised Stepped Wedge Trial of Opioid Sparing Analgesia in Emergency General Surgery.

BACKGROUND: Emergency general surgery (EGS) is associated with high postoperative pain burden and historically relies on opioid-centric analgesia, which can delay recovery and increase opioid-related adverse events and longer-term exposure. Evidence for scalable, system-level opioid-sparing pathways in pragmatic emergency surgical settings remains limited, particularly in Asian tertiary health systems. METHODS: We conducted a pragmatic, multicentre and cluster-randomised stepped-wedge trial in 12 Chinese tertiary hospitals comparing usual care with a structured multimodal opioid-sparing perioperative analgesia pathway. The primary outcome was cumulative 48-h postoperative opioid consumption (oral morphine milligram equivalents, MME). Secondary outcomes assessed pain, recovery, safety and post-discharge opioid exposure. Mixed-effects models accounted for clustering and period effects. RESULTS: Of 3646 enrolled patients, primary outcome data were available for 3561 (97.7%). Mean 48-h opioid consumption decreased from 64.2 to 46.1 MME, with an adjusted reduction of -18.1 MME (95% CI = -21.4 to -14.7; p < 0.001) and a ratio of means of 0.76 (95% CI = 0.72-0.80; p < 0.001). High opioid exposure (> 100 MME) declined (17.2% vs. 9.9%; OR = 0.52), while opioid-free status at 48 h increased (8.0% vs. 17.7%; OR = 2.47) (both p < 0.001). Pain burden, recovery metrics, opioid-related adverse events and persistent opioid use at 30 days all favoured the intervention. CONCLUSIONS: A structured opioid-sparing pathway reduced early postoperative opioid exposure and improved recovery and safety outcomes in EGS, supporting wider implementation of multimodal opioid stewardship.