Hospital pharmacists can take lead in providing pain medicine guidance
Here are some expert suggestions
Clinical pharmacists have many skills that would be of great use on hospital pain management teams, including conducting thorough medication histories and doing medication reconciliation.
The key is for hospital pharmacists to become experts in pain medicine through post-graduate education and training, says David Craig, PharmD, BCPS, clinical pharmacy specialist and residency director in psychosocial, palliative care, and integrative medicine at Moffitt Cancer Center in Tampa, FL.
Pharmacists who have expertise in pain medicine have the skills to best manage patients with acute pain who also have substance abuse and psychiatric illness, Craig says.
As hospital pharmacists increase their experience and knowledge of pain management, here are some suggestions for how they can help improve patient care for those in chronic pain:
1. Evaluate patient's substance use.
A pharmacist should take a thorough medication history to find out which pain medication the patient has taken previously and which the patient currently is taking, Craig says.
"If the pharmacist could establish some rapport with the patient where the patient feels like the practitioner needs this information to effectively manage his pain, then he's more apt to give the pharmacist the information," Craig says.
"We often are consulted when primary care physicians need our help with patients who have chronic pain where the typical pain treatment algorithm for post-operative pain is not working," he notes. "Pharmacists can get in there and spend a little more time to find out why we're not making any headway with this particular pain regime."
But pharmacists will need some training to help them find out about the kinds of behaviors that patients are reluctant to admit to anyone.
For instance, a patient might have used opioids illegally and may still be using them. It will take a pharmacist both time and some training in how to develop the rapport necessary to find out this information, Craig says.
Using a pain treatment algorithm, hospital pharmacists could determine whether a patient's pain treatment is adequate or whether it might need an adjustment, he says.
"Most hospitals have a typical treatment for patients who have knee or hip replacement surgery," Craig explains. "But if the patient doesn't do well on the standard anti-inflammatory, then the pharmacist could be helpful in identifying which medicines the patient was taking at home and what other substances the patient was consuming, including smoking and drinking."
2. Ensure patient safety.
"Pharmacists are involved in medication safety in hospitals more than in any other setting, so a pharmacist might determine if a particular dose is appropriate for this patient at her age," Craig says.
For instance, if a patient has a pain medication dose of 100 mg, the pharmacist should do a review to see what dosage the patient has been taking and assess whether the dosage is low, medium, or high for the patient, he says.
The prescription could be inadvisable based on the medication's potency or the patient's own tolerance of the drug, he adds.
Soon, hospital pharmacies will have new tools for ensuring patient safety when two new pain medications are approved, Craig notes:
- A new drug application for Embeda™, a morphine extended-release with sequestered naltrexone hydrochloride, was submitted to the FDA last year and was pending a decision as DFR went to press.
- The new drug application for Remoxy®, a long-acting formulation of oral oxycodone for moderate-to-severe chronic pain, was rejected in its present form by the FDA in December 2008, and the FDA said additional non-clinical data will be required to support the drug's approval. No additional clinical efficacy studies were requested by the FDA.
Both drugs were designed to be abuse-resistant, Craig says.
"That's the trend these days to reduce opioid abuse by having commercially available products that are less able to be abused," Craig says.
Patients sometimes will snort or inject oxycodone (OxyContin®), so some new pharmaceutical companies have created abuse-resistant products that will prevent tampering through large, extended-release formulation, Craig explains.
"Hospital will have to consider these at some point to be added to the formulary, although they come with additional costs," Craig says. "From a hospital's perspective, I think they possibly could add some additional patient safety."
Opioid abuse is a possibility with all pain patients.
Craig knew of one patient who was crushing oxycodone and mixing it in his chemotherapy port.
"So these new drugs would deter that type of problem, and from a safety perspective they do add something that's not yet available," he says.
Clinical pharmacists have many skills that would be of great use on hospital pain management teams, including conducting thorough medication histories and doing medication reconciliation.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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