Impact of a pharmacy‐led nursing education on discharge opioid prescribing after kidney transplant

A major contributor to the opioid epidemic is prescribing in the postoperative setting. There remains the need for opioid stewardship both postoperatively and upon discharge in kidney transplant recipients. In October 2017, pharmacist‐led education was given to all transplant nursing staff at a single center with the goal of optimizing postoperative pain control through education and empowerment of nurses. Furthermore, the education focus was to advance nursing knowledge, enhance patient assessment, and reform patient education. Clinical pharmacists continued to work with the transplant team to base a patient's discharge analgesia on inpatient analgesia use. This study assessed the impact of the nursing education on discharge analgesic prescribing patterns after kidney transplant admission. Opioid prescribing on transplant discharge was significantly lower after the education (pre 68.3% vs post 11.1%, P <.001). Transplant admission was shortened by 1 day (6 vs 5 days, P = .03). Over time, a significant downtrend in opioid prescribing was observed on discharge from 86.1% in 2015 to 49.6% in 2017 and 8.5% in 2018 (P <.001). If opioid therapy was required on discharge in the posteducation group, tramadol was predominantly prescribed (7/13 opioid prescriptions, 53.9%). Thus, opioid minimization and pain management using nonopioid analgesic prescribing on discharge are feasible in an adult kidney transplant population with proper nursing collaboration and education.


| INTRODUCTION
The opioid epidemic in the United States has triggered a national public health crisis. Opioid prescribing in the postoperative setting is a major gateway into opioid addiction and has been a large contributor to the opioid epidemic. 1,2 As the opioid epidemic has grown, various opioid minimization strategies were implemented in the setting of postsurgical analgesia. [3][4][5] Initiatives to limit opioid prescriptions have incorporated multimodal approaches including altering perioperative pain management, incorporating pain expectation education to patients, and systematic changes in opioid prescribing practices on an institutional level.
These approaches began to be implemented and described within the realm of both liver and kidney transplantation, resulting in reduced opioid utilization in both the peri-operative and postoperative settings. 6,7 In recent years, the opioid epidemic and its impact on outcomes of kidney transplant recipients has garnered significant interest in the transplant community. Various studies reported deleterious outcomes of opioid use pretransplantation. [8][9][10][11][12][13][14] Barrantes and colleagues demonstrated that 10.2% of their patients evaluated for transplantation were considered chronic opioid users (COUs) and reported regular, daily use of opioids for at least 3 months before receiving a kidney transplant. 8 While these patients experienced similar allograft outcomes to the non-COU cohort, they experienced worsened cumulative mortality at 1, 3, 5, and 7 years after transplant. 8 In another analysis, Lentine and colleagues found that 29% of their patients filled an opioid prescription in the year before transplantation. Those identified as high opioid users (exceeding 1000 morphine mEq per year) experienced an increased risk of death and all-cause graft failure. 13 Moreover, Wilson and colleagues and Patel and colleagues reported higher readmission rates and total readmission costs at 30-, 90-, and 365-days after transplantation in opioid experienced patients at the time of transplantation. 10,11 Continued use of opioids after transplantation has also been linked to poor outcomes. Kulshresta and colleagues reported increased hospitalization rates for patients that filled an opioid prescription in 3 or more of the 11 months in the year after transplantation. 12 Abbott and colleagues demonstrated increased mortality and graft loss with longterm opioid use; moreover, these outcomes worsened sequentially with daily doses of opioids exceeding 90 morphine milligram equivalents (MMEs). 14 Similarly, Lentine and colleagues linked high opioid use within the first year after kidney transplant with a higher risk of death and graft loss within the first 5 years after kidney transplantation. 13 Consequently, kidney transplant programs around the U.S. have implemented opioid minimization strategies. After implementing a multidisciplinary, multimodal, opioid minimization initiative, Rohan and colleagues described an immediate reduction in opioid use on discharge with 5% of patients in the multimodal pain protocol cohort discharged with an opioid prescription, compared with 96% of controls (P <.001). 6 This intervention was accomplished through multidisciplinary patient education, transversus abdominis plane or quadratus lumborum block with bupivacaine, and a postoperative multimodal pain regimen including scheduled acetaminophen and gabapentin. Similarly, Schwab and colleagues described a multidisciplinary approach that resulted in a reduction in opioid use during hospitalization but had little impact on opioid prescribing patterns on discharge (~25% of patients discharged with opioid prescriptions). 15 In the context of this study, their interventions included removal of the automatic postoperative patient-controlled analgesia pump and implementation of an opioid-sparing multimodal pain regimen, which included scheduled acetaminophen, lidocaine patch, and gabapentin.
In 2014, a ketorolac-based pain management protocol was implemented for peri-operative analgesia after donor nephrectomy at our center. Compared with a retrospective cohort, kidney donors who followed this opioid minimization protocol had a shorter length of stay (LOS), used less opioids, and had similar renal function outcomes. [16][17][18] While opioids were being minimized in kidney donors, kidney transplant recipients remained mostly discharged with opioids. Our pain management approach in kidney transplant recipients included rapid deescalation from opioid to nonopioid analgesia to ensure an adequate pain regimen by discharge (Table 1). In reviewing progress toward this goal, we observed that pain medications selected by the nurse and administered to patients frequently did not correlate with patient-reported pain scores documented within the electronic medical record (EMR). Consequently, a pharmacist-driven nursing education campaign was composed for transplant nursing staff. The purpose of this study was to assess the impact of a pharmacist-led nursing education on discharge analgesic prescribing patterns in adult kidney transplant recipients.

| Study design
This was a retrospective study assessing adult kidney transplant recip-

| Interventions
In October 2017, an education campaign focusing on opioid minimization was implemented to all bedside nurses within the solid organ transplant intensive care unit and the stepdown unit. The elements of the campaign included the importance of postoperative pain control, a review of opioid pharmacotherapy, pain assessment tools, clinical pearls in analgesic selection, and setting pain expectation goals with patients ( Figure 1). The key point of this training was to convey the need for accurate pain assessment and appropriate pain management while effectively stewarding opioids. First, the importance of pain control on the road to recovery and rehabilitation was reviewed as inadequate pain control has been shown to lead to reduced mobility, cardiac instability, and other negative effects on patient status. 19 Table 1, the goal under this opioid minimization strategy was to utilize nonopioids, such as acetaminophen, on discharge.
Therefore, medication education charts were revised to include acetaminophen rather than acetaminophen-hydrocodone to help patients anticipate, as early as postoperative day 1, that the goal will be to utilize acetaminophen for analgesia upon discharge. (pre 1.2% vs post 5.1%, P = .049) patients present in the posteducation group.

| Opioid prescribing at discharge and LOS
There was a significant reduction in the percentage of patients discharged with an opioid prescription after the education initiative (pre 68.3%. vs post 11.1%, P <.001). Figure 2 illustrates the overall changes in the percent of patients discharged with an opioid prescription preand post-educational efforts. Figure 3

| DISCUSSION
In the kidney transplant population, chronic opioid use before and after transplantation has been linked with worse outcomes. 8,12,14 These outcomes include increased readmission rates, higher hospitalization costs, delayed graft function, and increased risk of graft loss and death. Efforts to reduce opioid exposure in this population have been described by Rohan and colleagues and Schwab and colleagues with varying interventions described and varying degrees of success reported when it comes to discharge prescribing patterns. 6,15 Our study demonstrates that a dramatic reduction in opioid pre- program. The retrospective nature of this study also has the potential for human error during data collection. This study did not analyze preoperative opioid use. While preoperative opioid use data is not available to analyze, there were no changes at our center during this period regarding the pretransplant evaluation and listing process for patients on chronic opioids. Chronic pain conditions, inpatient opioid use, opioid prescriptions filled during outpatient follow-up, or readmissions due to uncontrolled pain were not analyzed. These items, along with renal function, patient survival, and graft survival, are currently being assessed in the context of the evolving pain protocol within our institution, and plan to be described in future analyses.
In conclusion, multidisciplinary efforts to successfully reduce opioid prescribing on discharge are feasible and necessary for suc-