Pharmacist-Led Intervention at Kaiser Permanente Northwest Reduces Opioid Use Among Hip Replacement Surgery Patients
For patients who received targeted outreach, median opioid use was about half that of patients who received only usual care.
David Smith, PhD, RPh
A pharmacist-led intervention that targeted patients undergoing joint replacement surgery led to a significant reduction in post-surgical opioid use among hip replacement patients, according to a Kaiser Permanente study published today in the American Journal of Managed Care. Knee replacement patients did not experience a comparable reduction.
Opioid use in the U.S. has exploded in recent years, from about 100 million prescriptions filled in 1992 to nearly 250 million in 2015. Orthopedic surgery is second only to primary care in generating the highest rates of opioid prescriptions among adults, with many patients using opioids both before and after surgery.
The study, conducted among 561 patients receiving either hip or knee replacement surgery at Kaiser Permanente Northwest, randomized half the patients to usual care and half to an intervention consisting of three parts. First, patients received a mailed brochure before surgery describing what they should expect regarding opioid use and pain control after surgery. Second, they received a follow-up brochure after surgery with additional information. Finally, patients who filled a prescription for opioids 28 to 90 days after surgery received a follow-up phone call from a pharmacist who used motivational enhancement techniques to reinforce the information and engage the patients in discussion.
Overall, the effects were similar between intervention and usual care patients. But for patients who underwent hip replacement therapy, the intervention had clinically and statistically significant effects on opioid use. For this group of patients, median opioid use was about half for the intervention group compared to the usual care group. Patients who received knee replacement therapy did not experience the same reduction.
“There’s no question that opioids play an important role in managing pain for orthopedic surgery patients,” said David Smith, PhD, RPh, a Distinguished Investigator at the Kaiser Permanente Center for Health Research and lead author of the study. “However, previous research has shown that once patients use opioid therapy for 90 days, they’re more likely to keep using it for years. Our study showed that by identifying the patients at highest risk and reaching out to them with educational materials and specialized, targeted telephone support, we can successfully encourage them to reduce their immediate post-surgical opioid use, potentially mitigating the risk of longer-term use.”
Dr. Smith added, “This is an intervention that can be adapted to many settings, but as an integrated care delivery system with its own pharmacies, Kaiser Permanente is an ideal setting to test this kind of intervention. Our pharmacists had specific training in opioid use and communication techniques such as motivational interviewing.”
For the study, researchers used Kaiser Permanente’s electronic health record system to identify patients over the age of 20 who were scheduled to undergo total hip or total knee replacement surgery. The research team then used a prediction model they developed to rank these patients according to their risk of being persistent opioid users in the 90–180 days following surgery. Patients with a predicted risk in the top 60% were enrolled in the study.
It is not yet clear why the intervention was ineffective in patients who had knee replacement surgery, but the researchers believe this may be related to the greater magnitude and duration of pain associated with knee replacement surgery, among other possible reasons.
The FLOOD (FDA: Lowering Orthopaedic Opioid Dosing) study was a two-arm, randomized, pragmatic clinical trial funded by the Food and Drug Administration (FDA contract number: HHSF22301400146C) and registered with Clinicaltrials.gov (NCT02576392).