Across the Continuum: Optimizing Strategies for Acute to Chronic Pain Management A Managed Care and Consultant Pharmacist Perspective
J. Richard Brown, PharmD, FASHP*
Pain, defined by the American Academy of Pain Medicine as an unpleasant sensation and emotional response to that sensation,1 is one of the most common physical complaints among society. While acute pain, which is usually a result of disease, surgery, or soft tissue injury, is generally short-lived,2,3 chronic pain may occur in the absence of injury, or may persist long after the initial trauma has subsided.2,4 Although the physiologic purpose of pain is to warn an individual of previous or impending injury, persistent pain does not serve any valuable function,5 and may, in fact, significantly interfere with an individual's ability to function. By making it difficult to sleep, work, socialize with friends and family, or accomplish daily tasks, ongoing pain often leads to depression and a diminished quality of life.6
Typically, pain is first detected by nociceptive receptors located in the periphery, deep tissues, and viscera. The release of prostaglandins, bradykinin, histamine, and neurosignaling chemicals such as norepinephrine helps to activate nociceptors and project the afferent pain signal to the dorsal horn of the spinal cord, from which it is relayed to the thalamus and cerebral cortex.7 Importantly, each point along this pathway is a potential site of intervention because the pain signal can be modulated by descending input from higher centers.
Mild-to-moderate pain can generally be managed with nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, whereas opioid analgesics may be necessary for the appropriate treatment of severe acute or chronic pain.8 Unfortunately, factors such as prescription drug abuse, legal implications, adverse events, and social stigma often preclude the use of opioids, resulting in inadequate pain management.9 It is important that such challenges be overcome in order for patients with pain to receive the level of care they require and deserve.
Appropriate pain management is especially important from a managed care perspective because managed care organizations are responsible for controlling the costs of healthcare services, which patients with untreated chronic pain are far more likely to utilize.10 Additionally, both managed care and consultant pharmacists play a key role in the management of pain patients through patient education and medication monitoring. Moreover, many consultant pharmacists work in institutional settings such as nursing homes, where pain is a prevalent issue; thus, it is important for them to be aware of the various agents available for the treatment of pain, as well as their place in therapy.
This issue of University of Tennessee Advanced Studies in Pharmacy is based on the proceedings from a roundtable symposium held in Orlando, Florida, on April 14, 2009, which included educational presentations and interactive discussions regarding pain management. This monograph is intended to provide managed care and consultant pharmacists with the tools needed to understand pain and to recognize the importance of optimizing pain therapy.
The monograph begins with a review of acute, chronic, and neuropathic pain, and follows with a discussion of the issues underlying inadequate pain management, as presented by Peter J. Koo, PharmD. The second article, by Robert L. Barkin, PharmD, MBA, FCP, DAAPM, DAAFE, reviews the therapeutic application of commonly used analgesics, including NSAIDs, acetaminophen, antiepileptic medications, antidepressants, skeletal muscle relaxants, topical agents, and opioid analgesics. The third article, presented by Bruce R. Canaday, PharmD, FASHP, FAPhA, examines some of the challenges standing in the way of appropriate pain management, and outlines how these obstacles may best be dealt with. The final article, by Sheldon J. Rich, RPh, PhD, explains how optimal patient management, including the early recognition and assessment of pain, can help to reduce healthcare costs and improve a patient's overall comfort and healthcare. Furthermore, this article discusses appropriate formulary decision making, and how it can be used to minimize long-term costs related to inadequate pain management. Additional participants who contributed to the roundtable discussion included J. Richard Brown, PharmD, FASHP, of the University of Tennessee, Scott Strassels, PharmD, PhD, BCPS, of the University of Texas at Austin College of Pharmacy, Kathryn L. Hahn, PharmD, DAAPM, of the Oregon State University College of Pharmacy, and Arthur G. Lipman, PharmD, FASHP, of the University of Utah Health Sciences Center.
Pharmacists are an integral part of the interdisciplinary team that is responsible for the management of pain. Increasingly involved in many aspects of patient care, pharmacists are uniquely positioned to contribute substantially to pain management in all settings and throughout the continuum of care, from acute treatment through chronic pain management. Unfortunately, managing pain has remained a challenge despite the availability of analgesics and tools designed to assist healthcare professionals in optimizing patient care.11 Thus, ongoing education is necessary to ensure that pharmacists keep abreast of new therapeutic developments, understand how to assess pain and make sure it is treated promptly and adequately, and regularly communicate with patients to minimize abuse and optimize treatment.
1. Definition of pain. Pain-Management-Info.com. Available at: http://www.pain-management-info.com/definition-of-pain.htm. Accessed May 15, 2009.
2. Woolf CJ. Somatic painÑpathogenesis and prevention. Br J Anaesth. 1995;75:169-176.
3. Acute vs. chronic pain. Medical Moment Web site. Available at: http://www.medicalmoment.org/_content/ facts/sep03/164021.asp. Accessed April 28, 2009.
4. Pain management: pain basics. WebMD Web site. Available at: http://www.webmd.com/pain-management/guide/pain-basics. Accessed April 28, 2009.
5. Dartmouth-Hitchcock Medical Center: Annual Report 2004. Available at: http://www.dhmc.org/dhmc-internet upload/ file_collection/DHMC_04_Annual_Report.pdf. Accessed May 15, 2009.
6. Richards KL. Understanding chronic pain. Chronic PainConnection.com. Available at: http://www.healthcentral.com/chronic-pain/fibromyalgia-287065-5.html. Accessed August 26, 2009.
7. Neuroanatomy of pain. Perioperative Pain.com. Available at: http://www.perioperativepain.com/Neuroanatomy_of_ Pain.htm. Accessed May 15, 2009.
8. Neurologic disorders: pain. The Merck Manuals Online Medical Library. Available at: http://www.merck.com/ mmpe/sec16/ch209/ch209a.html. Accessed May 15, 2009.
9. Morley-Forster PK, Clark AJ, Speechley M, Moulin DE. Attitudes toward opioid use for chronic pain: a Canadian physician survey. Pain Res Manag. 2003;8:187-188.
10. Sipkoff M. Pain management: health plans need to take control. Manag Care. 2003. Available at: http://www.managedcaremag.com/archives/0310/0310.pain.html. Accessed April 24, 2009.
11. Tzschentke TM, Christoph T, Kogel B, et al. (-)-(1R,2R)-3-(3-dimethylamino-1-ethyl-2-methyl-propyl)-phenol hydrochloride (tapentadol HCl): a novel mu-opioid receptor agonist/norepinephrine reuptake inhibitor with broad-spectrum analgesic properties. J Pharmacol Exp Ther. 2007;323:265-276.
*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: email@example.com.