A pharmacist-led telephone risk assessment clinic improved adherence to clinical guidelines and changed opioid prescribing practices in more than one third of assessed patients.

Purpose Guidelines recommend evaluating the risk of opioid-related adverse events prior to initiating opioid therapy. The orthopedic service at San Francisco Veterans Affairs Health Care System (SFVHCS) has not routinely used risk assessment tools such as the Stratification Tool for Opioid Risk Mitigation, prescription drug monitoring program data, and urine drug screening prior to opioid prescribing. A quality improvement project was conducted to evaluate the number of pharmacist-provided opioid risk mitigation recommendations implemented by orthopedic providers for patients who underwent total hip or knee arthroplasty at SFVHCS. Summary A pharmacist-led workflow for completing risk mitigation reviews was developed in collaboration with orthopedic providers, and urine drug screening was added to the preoperative laboratory testing protocol. The following recommendations were communicated via electronic medical record: limit postoperative opioids to a 7- or 14-day supply based on risk of suicide and/or overdose, offer naloxone and a medication disposal bag, and order a urine drug screen if not already completed. Risk reviews were completed for 75 patients. Among 64 patients with 2-month postdischarge data available, 88% (7 of 8) of 7-day and 79% (44 of 56) of 14-day opioid supply recommendations were implemented; 41% (26 of 59) of recommendations to issue a medication disposal bag, 17% (2 of 12) recommendations to order a missing urine drug screen, and 9% (5 of 55) of recommendations to offer naloxone were implemented. Conclusion Pharmacist-performed risk mitigation reviews paired with individualized recommendations led to high rates of orthopedic provider acceptance of limiting postdischarge opioid day supplies for patients who had total hip or knee arthroplasty. Alternative strategies may increase access to naloxone. Future research should examine the impact of risk mitigation tools in reducing prescribing of long-term opioid therapy and adverse events among orthopedic surgical patients.

Background: Up to 35% of veterans with opioid use disorder (OUD) are homeless, and veterans with OUD are nearly 29 times higher risk for homelessness; however, few are prescribed naloxone, an evidence-based intervention to reverse life-threatening opioid overdose. Local problem: Many housing facilities for homeless veterans contracted with the San Francisco Veterans Affairs Health Care System are located in neighborhoods with high rates of opioid overdose. No systematic interventions have been implemented to provide opioid overdose education and naloxone kits to veterans and staff at these facilities. This quality improvement (QI) initiative aimed to increase provision of opioid overdose education and naloxone for veterans and staff at contracted housing facilities. Methods: This was a prospective single-arm cohort QI intervention. All contracted veteran housing programs were included. Descriptive statistics evaluated results. Interventions: A total of 18 contracted veteran housing programs were contacted from July 2019 through January 2020 to schedule training. Results: Of those, 13 programs responded to outreach and 10 visits were completed at 8 housing facilities. Training was provided by pharmacist and nurse practitioner trainers to 26 staff members and 59 veterans. Naloxone was prescribed to 37 veterans. Conclusions: A pharmacist-led and nurse practitioner–led initiative was effective in increasing veteran and staff access to opioid overdose education and naloxone at >44% contracted veteran housing facilities. Challenges included lack of response from housing programs, low veteran turn out, and inability to provide naloxone to veterans not enrolled/ineligible for health care. Future initiatives should examine strategies to standardize access in homeless veterans' programs.