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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


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.


opioid, acute pain, pharmacist

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