The impact of an innovative pharmacist-led inpatient opioid de-escalation intervention in post-operative orthopedic patients

Thuy Bui, BPharm; Richard Grygiel, MPharm; Alex Konstantatos, MB BS (Hons), FANZCA, Dip Obs, MRCA; Nick Christelis; Susan Liew, MB BS (Hons), FRACS; Ria Hopkins, BHSci (Hons), MPH; Michael Dooley, BPharm, Grad DipHospPharm, PhD

doi:10.5055/jom.2020.0565

Authors

Thuy Bui, BPharm
Richard Grygiel, MPharm
Alex Konstantatos, MB BS (Hons), FANZCA, Dip Obs, MRCA
Nick Christelis
Susan Liew, MB BS (Hons), FRACS
Ria Hopkins, BHSci (Hons), MPH
Michael Dooley, BPharm, Grad DipHospPharm, PhD

DOI:

https://doi.org/10.5055/jom.2020.0565

Keywords:

opioid, acute pain, pharmacist

Abstract

Objective: Many patients are discharged from hospital after surgery with excessive doses of opioid, and prescription opioid addiction has become a serious public health problem. Inpatient opioid de-escalation performed by clinical pharmacists may assist in reducing opioids before discharge. We aimed to evaluate whether clinical pharmacist-led opioid de-escalation for inpatients after orthopedic surgery led to significant reductions in opioid use at discharge, without resulting in greater pain intensity and side effects.

Design: This retrospective pre-/post-intervention study evaluated patients before and after implementation of a pharmacist-led opioid de-escalation service.

Setting: A major tertiary institution.

Participants: Ninety eight participants underwent de-escalation, and 98 controls received standard care following orthopedic surgery.

Intervention: Pharmacist-led opioid de-escalation was initiated after discharge from the institution's Acute Pain Service.

Main outcome measure: Primary outcome was total morphine oral equivalence (MOE) required in the 24-hours before discharge between the two groups. Secondary outcomes included pain intensity scores and opioid-related side effects.

Results: The post-intervention group used significantly less opioids in the 24 hours preceding discharge compared with the precohort (total MOE 30 vs 45 mg; p = 0.025).There were no differences in pain intensity at rest (p = 0.19) or with movement (p = 0.19). Cases experienced significantly less constipation (29 vs 49 percent; p = 0.004); no differences were observed for other side effects.

Discussion: We observed statistically similar pain intensity ratings, in the setting of significantly lowered opioid doses among the post-intervention group prior to discharge.

Conclusion: Pharmacist-led inpatient opioid de-escalation is effective, does not increase pain intensity, and reduces constipation. Hospitals should explore the viability of extending pharmacist-led opioid de-escalation to other surgical patients and following hospital discharge, aiming for opioid cessation.

Author Biographies

Thuy Bui, BPharm

MClinPharm, Pharmacy Department, Alfred Health, Melbourne, Australia; Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia

Richard Grygiel, MPharm

Pharmacy Department, Alfred Health, Melbourne, Australia

Alex Konstantatos, MB BS (Hons), FANZCA, Dip Obs, MRCA

Anaesthesia and Perioperative Medicine Department, Alfred Health, Melbourne, Australia; Central Clinical School, Monash University, Melbourne, Australia

Nick Christelis

Anaesthesia and Perioperative Medicine Department, Alfred Health, Melbourne, Australia; Central Clinical School, Monash University, Melbourne, Australia

Susan Liew, MB BS (Hons), FRACS

Central Clinical School, Monash University, Melbourne, Australia; Department of Orthopaedic Surgery, Alfred Health, Melbourne, Australia; Monash University Department of Surgery, The Alfred, Melbourne, Australia

Ria Hopkins, BHSci (Hons), MPH

Pharmacy Department, Alfred Health, Melbourne, Australia; School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia

Michael Dooley, BPharm, Grad DipHospPharm, PhD

Pharmacy Department, Alfred Health, Melbourne, Australia; Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia

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