Changes in postoperative inpatient and outpatient opioid utilization after pharmacist‐led order set standardization and education for total knee and hip replacement at an academic medical center

Abstract

AbstractIntroductionOpioid analgesics are often overprescribed after orthopedic procedures. Several strategies have been implemented nationally to curb opioid overprescription with modest success. At an institutional level, one novel idea is to implement surgery‐specific guidelines limiting opioid quantities prescribed postoperatively.ObjectivesThe primary objective of this study was to evaluate the effect of our institution's new standardized postoperative multimodal pain regimen guidance on cumulative opioid prescribed postoperatively at discharge, as measured in morphine equivalent dose (MED).MethodsAdults (≥18 years old) who underwent total knee or total hip replacement from August 2019 through March 2020 were eligible. Patients not prescribed opioids at discharge, incarcerated, or had postoperative stays 7 or more days were excluded. A pharmacist‐led standardized protocol was implemented on 21 November 2020, and provider education was completed on 18 December 2021. Patients were assigned to historical (August 2019 to November2019) or standardized (December 2019 to March 2020) cohorts based on discharge date. Secondary outcomes are cumulative and per‐prescription opioid pills, morphine equivalent daily dose (MEDD) prescribed at discharge, inpatient opioid, diazepam, and gabapentin utilization, and outpatient post‐op opioid and pain outcomes.ResultsForty patients preintervention and 52 patients postintervention were included. For postoperative discharge opioids prescribed, median cumulative MED decreased 46% (560.0 vs 300.0, P < .001), quantity of pills decreased 14.3% (70 vs 60, P = .03), and MEDD decreased 16.7% (60.0 vs 50.0, P < .001). Inpatient opioid exposure decreased 49% (38.1 vs 19.4, P < .001), concurrent diazepam (20.0% vs 1.9%, P = .009), and gabapentin (85.0% vs 13.5%, P < .001) use with opioids also decreased. Postoperative pain scores did not significantly differ (4.0 vs 5.0, P = .63).ConclusionPharmacist‐led standardized protocol implementation resulted in reduced postoperative opioid prescription and exposure, and decreased concurrent use of high‐risk drugs without affecting pain control. Opportunities exist to further decrease opioid prescribing by matching inpatient requirements.