ACROSS THE CONTINUUM: OPTIMIZING STRATEGIES FOR ACUTE TO CHRONIC PAIN MANAGEMENT
J. Richard Brown, PharmD, FASHP*
ain is among the most common conditions encountered by pharmacists and other healthcare professionals. It has been estimated that approximately 25 million people in the United States experience acute pain each year due to accidents, injuries, or surgery, and more than 76 million individuals suffer from chronic pain.1 Effective pain management is clearly important to help relieve patient distress and improve quality of life. Poorly controlled pain has been associated with many other adverse health outcomes, including higher levels of stress, suppression of endocrine and immune function, slower healing, increased likelihood of surgical complications, and higher total treatment costs.2-4 In addition, considerable recent research has demonstrated that patients with inadequate treatment of acute pain are at increased risk of developing chronic pain,5,6 and laboratory studies have suggested that even a relatively short period of acute pain can initiate long-term remodeling of the central nervous system in ways that cause persistent increases in pain perception.7-9
Despite the ubiquity of pain and the fact that pain medications are the second most commonly prescribed class of drugs (following only cardiac-renal drugs),10 many experts have argued that inadequate pain control remains a common problem among patients with acute or chronic pain.11-13 Even patients who are hospitalized following surgery often struggle to achieve adequate pain control. In one nationwide survey of hospitalized postsurgical patients, pain was described as “severe” by 21% of patients and as “extreme” by 18%.14 Surveys of patients with chronic pain also report high levels of dissatisfaction with pain control that is achieved in typical clinical practice.15
Opioid analgesics are effective and safe treatments for moderate-to-severe pain, yet several barriers prevent the effective management of pain for many patients. Adults with pain are often reluctant to seek medical assistance, either because they believe that nothing can be done for the pain, or because they are unwilling to use pain medications due to concerns about the risk of adverse effects.12 Both patients and clinicians often fear the potential for opioid addiction, which can lead to avoidance of pain medication or the use of ineffective strategies. Pharmacists are often wary of medication diversion or other forms of nonmedical use. Although the abuse and diversion of prescription pain medications are clearly important problems, several studies have demonstrated very low rates of iatrogenic drug addiction among individuals using opioids for acute or chronic pain who do not have substance use problems before beginning therapy.16-18 It is also important to distinguish drug addiction from pseudoaddiction, a phenomenon in which patients with inadequate analgesia act in ways that superficially resemble drug addiction, such as obtaining prescriptions from multiple physicians or filling prescriptions early.19 Other potential obstacles to optimal pain management include the relatively limited education that most clinicians receive about pain during training, inadequate assessment of pain, institutional resistance to practice change, and legal or regulatory barriers to opioid prescribing.20-22
Pharmacists are at the forefront of the management of patients with pain. Many patients with pain or questions about their pain medications first discuss these issues with a pharmacist. Pharmacists dispense medications, perform follow-up assessments of treatment response, educate patients about how to use their medications and what to expect from therapy, help patients manage medication side effects, and identify treatment regimens that are not working well. In addition to their role as clinicians who are directly involved in relieving patient pain and distress, pharmacists also have significant legal and ethical responsibilities to ensure that opioid medications are not used inappropriately.
This issue of University of Tennessee Advanced Studies in Pharmacy, which is based on a satellite symposium conducted in conjunction with APhA2009 in San Antonio, Texas, on April 4, 2009, provides an update on recent developments in the management of pain. This activity has been designed to address current topics in pain care that are of particular importance to practicing pharmacists, including emerging treatment options, breaking scientific news, the relationship between methadone use and cardiac QTc prolongation, US Food and Drug Administration guidance on prescription medication abuse, and the implications of the Controlled Substances Act of 1970 for pharmacists who treat patients with pain. In the first article, Robert L. Barkin, PharmD, MBA, FCP, DAAPM, describes his approach to the assessment of the patient with pain and reviews factors that influence the selection of treatment. He emphasizes the importance of a thorough clinical interview, an understanding of the specific pain etiology, the various types of opioid and nonopioid medications that are available for pain management, the importance of drug metabolism in analgesia efficacy and safety, and recent changes to the general approach to pain management. In the second article, Bruce R. Canaday, PharmD, FASHP, FAPhA, provides an overview of the market for pain management medications and devices, how pain management in contemporary clinical practice fails to achieve important goals for many patients, and some of the obstacles that prevent more effective pain control. He also considers some of the important legal and ethical issues that are involved in the prescribing and dispensing of controlled substances.
At the conclusion of this activity, readers should be better able to describe the characteristics and impact of acute and chronic pain, identify and overcome obstacles to pain treatment, and develop effective strategies to help patients achieve the best possible outcomes with their pain therapy.
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*Professor, Clinical Pharmacy, Colleges of Pharmacy and Medicine, University of Tennessee, Memphis, Tennessee.
Address correspondence to: J. Richard Brown, PharmD, FASHP, Professor, Clinical Pharmacy, Colleges of Pharmacy and Medicine, University of Tennessee, 119 Veterans Affairs Medical Center, Memphis, TN 38104. E-mail: firstname.lastname@example.org.
The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his article and all its contents.