A Multidisciplinary Approach to Reduce Prolonged Postoperative Opioid Use in High-risk Patients

We conducted a retrospective chart review of all Veterans who received a perioperative PharmD e-consult from the program’s inception in October 2023 through September 2024. The e-consult consisted of virtual chart review by a clinical pharmacist to assess pertinent medical history with a focus on chronic pain, current medications, SUD, and psychiatric comorbidities. Providers were given inpatient and postoperative multimodal pain management plans. Descriptive statistics were used to analyze Veteran demographics, in addition to surgical team fidelity to multimodal recommendations (process measure) and pre- and postoperative pain prescriptions and surgical outcomes through 90 days postoperatively (outcome measures). This quality improvement initiative meets the SQUIRE criteria for QI reporting. The e-consult program provided perioperative pain management recommendations for 51 Veterans. The most frequent reasons for the e-consult were chronic opiate use preoperatively (39.2%; defined as use for 60 consecutive days or ≥ 3 prescriptions in 90 days preoperatively) and a history of SUD (34%). Consults were initiated by the preoperative assessment team or surgical teams. Most Veterans in the cohort were male (90.2%), with median (IQR) age 65 (48–71) years and Risk Analysis Index frailty score of 25 (17–37). There was a high prevalence of psychiatric conditions (94.1%) and SUD (51.0%). Most Veterans (76.5%) used opiates chronically in the preoperative setting. Among chronic opiate users, most were prescribed opiates for chronic pain (64.1%), though some were prescribed Medication for Opiate Use Disorder (MOUD) (35.9%). These results are summarized in Table 1 . Of 39 Veterans who underwent surgery, 22 (56.4%) required an inpatient stay. Inpatient pain management recommendations were partly followed 95.5% of the time and completely followed 4.5% of the time. Discharge pain management recommendations were partly followed by 32 (82.1%) and fully followed by 7 (17.9%) discharging teams; 18 (46.2%) Veterans were discharged with the pharmacist-recommended opiate plan. At 90 days postoperatively, 32 (82.1%) Veterans had reverted to their preoperative opiate requirement. This included 8 of the 9 Veterans who did not take any opiates preoperatively. There were 3 Veterans who required a higher dose of chronic opiates, 1 who had been on MOUD remotely in the past year and resumed MOUD postoperatively, 2 who were lost to follow-up, and 1 mortality.