Pharmacists need to be involved in a pain management team
Experts offer examples of support role
Hospitals need a pharmacist who specializes in pain management on board, although this model hasn't taken off as a trend as quickly as many experts in the field believe it should.
"There really wasn't a lot of recognition of health systems even needing pain services until the 1980s with the hospice movement," says Virginia Ghafoor, PharmD, a clinical pharmacy specialist in pain management at the University of Minnesota Medical Center—Fairview in Minneapolis, MN, and a clinical pharmacy specialist in pain/palliative care at Fairview Ridges Hospital in Burnsville, MN.
As hospice and palliative care programs began to grow, there was an evolution in health systems offering pain management services, she adds.
"In the 1990s, we started seeing the impact of the aging population having pain problems, including degenerative joint diseases, neuropathic pain, and other types of chronic pain," Ghafoor says.
This led to the development of new drugs for treating neuropathic pain, including gabapentin (Neurontin®) and pregabalin (Lyrica®), Ghafoor notes.
"So what has happened is there's a growing demand to have people who are specializing in chronic pain for both pain management and for a multidisciplinary approach," she explains.
"Pain is a big topic," says Lee Kral, PharmD, BCPS, a clinical pharmacy specialist in pain medicine at the University of Iowa Hospitals and Clinics in Iowa City, IA.
Pain medication management involves psychosocial, substance use, regulatory, and diversion/abuse issues, making it a very complex pharmacy specialization, the experts say.
"A lot of the issues we face are post-op pain, and that's huge—especially in hospitals," she adds. "If you don't have a team that goes around and sees patients in the recovery room, then pain management can be a problem."
While every pharmacist should have a basic knowledge about pain medicine, there's also a need for pharmacists who are specialists in pain medicine, Ghafoor says.
Hospitals increasingly are asking pharmacists to start pain services, and the pharmacist's role in pain services needs to grow, but there also needs to be more resources budgeted to train pharmacists in this practice, Ghafoor says.
"A lot of pharmacists have learned about pain medicine on the side, and they really don't have a lot of formal training," she adds. "They need more structured training before they take on a service like this all by themselves."
The problem is that pharmacists traditionally receive only a few hours of pain medicine education as students, so most of the training comes post-graduation, says David S. Craig, PharmD, BCPS, a clinical pharmacist specialist and residency director in psychosocial, palliative care, and integrative medicine at Moffitt Cancer Center in Tampa, FL.
"There's a big movement in hospitals to incorporate palliative care in end-of-life care and pain management," Craig notes. "And this is one of those areas where hospital pharmacists can get involved with patients."
But the pharmacists will need to be trained in pain medicine, he adds.
Hospital pharmacists often are too busy to obtain the training on their own, and hospitals typically do not invest in creating a role for a pharmacist pain medicine specialist, Craig says.
"We have a pharmacy pain management program here, and there are two others in the United States," Craig says. "So that makes three pain management pharmacy programs in the United States."
Hospitals are recognizing the need for better pain management, however.
"What you find is that hospitals have been forced into looking at pain management in a much more serious light because of recent Joint Commission [on Accreditation of Health Care Organizations] standards," says Christopher Herndon, PharmD, BCPS, an assistant professor at Southern Illinois University—Edwardsville in Edwardsville, IL.
"This makes it a perfect storm for pharmacists to be involved," Herndon adds.
The American Society of Health-System Pharmacists (ASHP) recently featured an all-day session on pain management at its 43rd Mid-Year Clinical Meeting, held Dec. 7-11, 2008, in Orlando, FL. Craig, Ghafoor, Herndon, and Kral spoke about pain management at the conference.
ASHP is working to develop pain medicine residency standards for pharmacists, Craig says.
"ASHP is trying to highlight and inform hospital pharmacists who are out of school and practicing now to give them the tools they need to incorporate these standards into their own practices," he says. "But this is only for the pharmacists who are motivated and interested in the pain medicine field; it'd be nice if there were standards for all hospital pharmacists."
For example, pharmacists in community hospital settings can play a big role in helping manage acute pain for patients post-surgery, Craig says.
"One of the issues that always comes up is how do you effectively manage the patient's pain when the patient has a substance abuse disorder or a psychiatric disorder," Craig says. "Those patients become a challenge for most clinicians, and so physicians will ask for assistance with that, and pharmacists should be involved."
The University of Iowa Hospitals and Clinics has about 100 pharmacists, including many who are involved in internal medicine and patient care issues that also involve pain management, Kral notes.
"But what's unusual is we actually pay one pharmacist—me—to do nothing but pain management full-time," Kral says.
At the minimum, it's important to have a pharmacist involved in the pain management team, Kral and other experts say.
Hospitals are beginning to create teams of pharmacists and nurses to run inpatient pain and symptom management programs, and a number of larger teaching institutions now have pharmacists involved in their pain teams, Herndon says.
But this hasn't translated into creating pain management pharmacy specialists as is ideal, he notes.
"We did a large survey of hospitals three or four years ago, asking what is the largest thing precluding hospitals from assigning a pharmacist either full-time or part-time to pain management, and it all came back to resources and budget," Herndon explains. "The doctors are all for it and the directors are for it, but it's a soft cost service because we can't bill for it."
There are a number of reasons why pain management should include pharmacy input, including the following:
• Physicians need assistance: Physicians on rounds might decide to make changes to patient's opioid use, and if they do, the pharmacist is the person they might call for assistance.
"Pharmacists are the best practitioners in a hospital setting to be responsible for the ongoing monitoring and adjustment of in-house pain and symptom management," Herndon says. "A lot of hospitals are realizing this, and if the resources are there to free up pharmacists, then that's the dream."
• Hospitals are enhancing palliative care services: Many hospitals are starting to add or enhance their palliative care services, Herndon says.
"A large reason for this is to provide better patient care," he adds. "This is a way for pharmacists to get involved in an area where hospitals already are putting resources."
For instance, Herndon is associated with a hospital that doesn't have an inpatient pain management team, but it does have an inpatient palliative care team.
"We are utilized as an inpatient pain service group," Herndon says.
• Pharmacists can help with patient screenings and monitoring: It helps to have a pharmacist on board, particularly in the more complicated pain medicine cases.
Some patients with little opioid experience could become over-sedated, a problem that easily could be prevented if a pharmacist was involved to evaluate and monitor the patient's situation, Kral says.
"Floor nurses with 6-8 post-op patients don't have the time and resources to more acutely monitor a patient's pain," Kral adds.
"We monitor for possible acute renal insufficiency post-operation," Kral says. "Does the patient have sufficient renal output and are the kidneys clearing the medicines?"
Also, the University of Iowa Hospitals and Clinics' pain medicine team screens patients for undiagnosed sleep apnea, since these patients may be at risk for respiratory depression with opioids, she says.
"Also, it's important to know if the patient has been on opioids at home because if they've been taking opioids at home and then come in for knee replacement surgery, then their pain needs post-operatively will be greater, and sometimes that's not covered adequately," Kral says. "So a pharmacist on these teams makes sure the home medications are either restarted or the pain is covered with some kind of infusion or patient controlled analgesia (PCA) opioid doses."
The point is that pharmacists should be involved in hospital pain management and palliative care because of the skills and knowledge they can bring to the role, Herndon says.
"I really think this is an area where pharmacists excel above other providers or other allied health care professionals because of our knowledge of the way medications work and how they are dosed," Herndon says. "There are so many things that go into keeping patients on so many pain medications, and this is an area that physicians are willing to delegate."
Hospitals need a pharmacist who specializes in pain management on board, although this model hasn't taken off as a trend as quickly as many experts in the field believe it should.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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