Exploring a pharmacist-led, opioid medicines use review post-surgery: A prospective multicentre non-randomised, proof-of-concept study

Technical Summary: Pharmacist-Led Opioid Medicines Use Review Post-Surgery

Problem Statement
Opioids remain a cornerstone for managing acute post-surgical pain; however, prolonged use beyond the immediate recovery period significantly increases risks of dependence, adverse events, and persistent opioid use. Despite recent UK guidance emphasizing early review and deprescribing, practical implementation strategies within primary care remain under-explored. Surgical patients are particularly vulnerable, with studies suggesting 6–10% of opioid-naive patients transition to persistent post-operative opioid use. Current challenges include variability in discharge prescribing practices, the lack of structured follow-up mechanisms, and the difficulty in identifying eligible patients for timely intervention in general practice settings.

Methodology
This study was a prospective, multicentre, non-randomised, proof-of-concept feasibility study conducted across six General Practitioner (GP) practices in Southeast England. The intervention was a clinical pharmacist-led Medicines Use Review (MUR) focused on opioid deprescribing.

• Participants: Adults (≥18 years) discharged from a single NHS hospital with acute non-malignant post-surgical pain and prescribed opioids (<120 mg Morphine Milligram Equivalents [MME]/day). Exclusion criteria included pre-operative opioid use >90 days, pregnancy, or inability to consent.
• Intervention: Participants received a baseline MUR within 10 days of discharge. Clinical pharmacists, trained in opioid de-escalation, facilitated shared decision-making to assign patients to one of three pathways:
  • Pathway A: Rapid de-escalation (cessation or 10–50% daily dose reduction).
  • Pathway B: Gradual tapering (10–50% weekly dose reduction).
  • Pathway C: Continuation of current regimen due to ongoing pain or complexity.
    Follow-up reviews continued until opioid cessation or 90 days post-discharge.
• Data Collection: Quantitative data included demographics, surgical details, opioid prescribing patterns, pain scores (0–3 scale), and EQ-5D-5L quality-of-life metrics. A micro-costing approach estimated intervention costs based on pharmacist time (NHS Agenda for Change Band 7). Qualitative data regarding acceptability was collected via surveys and interviews (reported separately).
• Analysis: Descriptive statistics were used for feasibility outcomes. Due to lower-than-anticipated recruitment, comparative statistical testing was limited.

Key Results

• Recruitment and Feasibility: The study recruited 23 participants (mean age 60 years; 45.5% male) over 11 months, significantly below the target of 80–100. Recruitment was hindered by difficulties in timely patient identification via manual screening of GP records and workforce capacity constraints within GP practices. Only two of the six initiated practices actively enrolled patients.
• Deprescribing Outcomes:
  • At baseline (average 5.7 days post-discharge), 22.7% of participants had already independently discontinued opioids.
  • Of those still taking opioids, 40.9% followed rapid tapering (Pathway A), 27.3% gradual tapering (Pathway B), and 4.5% continued use (Pathway C).
  • Crucially, all patients successfully discontinued opioid use within 31 days of discharge.
  • No participants were flagged for high-risk adverse events (e.g., overdose or diversion).
• Prescribing Variability: Post-surgical prescribing showed significant inconsistency. While most received immediate-release formulations, some were prescribed multiple concurrent opioids, and one patient received prolonged-release oxycodone, contrary to national guidance.
• Patient Experience and Cost:
  • Patient satisfaction was high; respondents reported confidence in pharmacist expertise and felt involved in decision-making.
  • The average intervention cost was £61.05 per participant, driven primarily by pharmacist time (mean 53 minutes total contact).
  • Pharmacists delivered the intervention with high autonomy, requiring additional support in only 7.1% of consultations.

Significance and Claims
The paper positions this study as a proof-of-concept demonstrating that pharmacist-led MURs are a feasible, acceptable, and potentially cost-effective strategy for supporting opioid deprescribing in the immediate post-surgical period.

• Clinical Feasibility: The study confirms that clinical pharmacists embedded in primary care can successfully identify, engage, and guide patients through structured deprescribing pathways, achieving 100% cessation within one month for the cohort.
• Systemic Integration: The intervention aligns with the clinical pharmacist's role in medicines optimisation and transitions of care, suggesting that such reviews can be integrated into routine primary care workflows with minimal additional infrastructure.
• Limitations and Future Directions: The authors modestly conclude that while the intervention is viable, scalability is currently limited by recruitment barriers (specifically patient identification) and workforce capacity. They assert that larger, adequately powered studies are required to establish clinical and cost-effectiveness definitively. Future work should focus on developing automated patient identification systems, risk stratification tools to target high-risk patients, and system-wide strategies to standardise discharge prescribing.

The study does not claim to have solved the opioid crisis but provides evidence that a specific, pharmacist-led intervention is a practical component of a broader stewardship strategy, warranting further investigation in a definitive trial.