HEALTH-SYSTEM PHARMACIST PERSPECTIVES
J. Richard Brown, PharmD, FASHP*
Pain management is an essential aspect of care for patients with a wide variety of medical conditions, including acute injury, surgery, migraine headache, arthritis, painful diabetic neuropathy, musculoskeletal pain, and pain due to cancer. Effective pain treatment helps to relieve patient discomfort and distress, improve quality of life, and restore the ability to function normally. Recent research has also demonstrated that the stress response caused by inadequately treated pain may slow the rate of wound healing, and that more effective treatment of acute pain can help to speed recovery after surgery.1,2 The undertreatment of acute pain has also been associated with an increased risk of transitioning from acute to chronic pain.3 It is therefore essential to identify individuals who are at risk of undertreated pain, and to develop management plans to reduce pain severity and prevent long-term disability.
Despite the central role of analgesia in medical care, many patients experience inadequate pain control and dissatisfaction with their pain management.4 There are many obstacles to effective pain treatment, including the failure to recognize or evaluate pain, to have or to use institutional pain management guidelines, or to assess the adequacy of analgesia.5 For example, a recent survey of interns, residents, and attending physicians at a large urban tertiary medical center found that only 23% of physicians were familiar with their institution’s pain management protocols.6 Even among pain specialists, selection of analgesic strategies is often not consistent with published evidence-based guidelines.7 The management of pain has become increasingly complex over the last decade as several new pain medications, drug formulations, and delivery systems have been introduced. As more products enter the market, treatment regimens become increasingly complex and the risk of drug interactions increases.
In addition, there has also been a growing concern about the risks of opioid abuse, diversion, and addiction. Although it is reasonable to exercise due caution when prescribing and dispensing opioids, these fears may significantly interfere with the ability of patients to attain pain relief.8 Several studies have demonstrated that the risk of opioid misuse or addiction in actual clinical practice is low, especially when these agents are used by individuals who have not previously had substance use problems.9 The use of opioids is also complicated by several opioid-related adverse events, such as respiratory depression, drowsiness, and constipation. In order to effectively use pain medications, healthcare professionals must be able to balance the benefits of pain treatment against potential adverse events while maintaining a high level of vigilance for individuals who are at risk of medication misuse, addiction, or diversion.
Health-system pharmacists are an integral part of the interdisciplinary pain management team, and are uniquely positioned to improve pain management in a variety of acute and chronic pain settings. They carry out several essential roles in the treatment of pain, including identifying patients who are using analgesic medications, attending rounds with physicians, assessing patient pain control, conducting patient education, and designing pain management programs for difficult-to-treat patients.10,11 Pharmacist participation in pain management protocols in hospitals or other healthcare systems has been shown to improve several outcomes related to pain management, including better pain relief, patient satisfaction, adverse-event monitoring, and lower overall treatment costs.12-14
This issue of University of Tennessee Advanced Studies in Pharmacy reviews some of the most important recent developments in pain management. It includes proceedings from a Midday Symposium conducted at the 44th ASHP Midyear Clinical Meeting and Exhibition in Las Vegas, Nevada, on December 8, 2009. The first article, by J. Richard Brown, PharmD, FASHP, provides an update on some recent developments related to the safety of analgesic medications, including the role of methadone in QTc interval prolongation and cardiac arrhythmias, new guidelines about efficacy and adverse effects associated with the use of nonsteroidal anti-inflammatory drugs, and concerns about accidental or intentional overdose with the opioid analgesic propoxyphene. The second article, by Robert L. Barkin, PharmD, MBA, FCP, DAAPM, discusses the importance of an individualized and patient-centered approach to pain management, and describes new opioid medications that have recently been approved for pain treatment. The monograph concludes with a discussion of the role of the health-system pharmacist in pain management by Bruce R. Canaday, PharmD, FASHP, FAPhA. Dr Canaday highlights some of the critical medical, ethical, and legal issues that health-system pharmacists must consider in effective pain management. After completing this activity, health-system pharmacists will be better able to describe current and emerging pain management strategies, recognize the medical and economic impact of inadequate pain management, and formulate strategies to optimize clinical outcomes for patients with many types of acute and chronic pain.
1. McGuire L, Heffner K, Glaser R, et al. Pain and wound healing in surgical patients. Ann Behav Med. 2006;31:165-172.
2. Broadbent E, Petrie KJ, Alley PG, Booth RJ. Psychological stress impairs early wound repair following surgery. Psychosom Med. 2003;65:865-869.
3. Katz J, Seltzer Z. Transition from acute to chronic postsurgical pain: risk factors and protective factors. Expert Rev Neurother. 2009;9:723-744.
4. Whelan CT, Jin L, Meltzer D. Pain and satisfaction with pain control in hospitalized medical patients: no such thing as low risk. Arch Intern Med. 2004;164:175-180.
5. Motov SM, Khan ANGA. Problems and barriers of pain management in the emergency department: are we ever going to get better? J Pain Res. 2009;2:5-11.
6. Douglass MA, Sanchez GM, Alford DP, et al. Physicians’ pain management confidence versus competence. J Opioid Manag. 2009;5:169-174.
7. Victor TW, Alvarez NA, Gould E. Opioid prescribing practices in chronic pain management: guidelines do not sufficiently influence clinical practice. J Pain. 2009;10:1051-1057.
8. Dobscha SK, Corson K, Flores JA, et al. Veterans affairs primary care clinicians’ attitudes toward chronic pain and correlates of opioid prescribing rates. Pain Med. 2008;9:564-571.
9. Noble M, Tregear SJ, Treadwell JR, Schoelles K. Long-term opioid therapy for chronic noncancer pain: a systematic review and meta-analysis of efficacy and safety. J Pain Symptom Manage. 2008;35:214-228.
10. [No authors listed] Experts discuss pain management issues. Healthcare Benchmarks Qual Improv. 2009;16:32-34.
11. Fan T, Elgourt T. Pain management pharmacy service in a community hospital. Am J Health Syst Pharm. 2008;65:1560-1565.
12. Briggs M, Closs SJ, Marczewski K, Barratt J. A feasibility study of a combined nurse/pharmacist-led chronic pain clinic in primary care. Qual Prim Care. 2008;16:91-94.
13. Brooks JM, Titler MG, Ardery G, Herr K. Effect of evidence-based acute pain management practices on inpatient costs. Health Serv Res. 2009;44:245-263.
14. Weidman-Evans E, Jacobs TF, Isherwood P, et al. Impact of a pharmacist-developed protocol on the cardiac monitoring of methadone in chronic noncancer pain management. J Am Pharm Assoc. 2009:e102-e109.
*Professor, Department of Clinical Pharmacy, Colleges of Pharmacy and Medicine, University of Tennessee, Memphis, Tennessee.
Address correspondence to: J. Richard Brown, PharmD, FASHP, Professor, Department of Clinical Pharmacy, Colleges of Pharmacy and Medicine, University of Tennessee, Veterans Affairs Medical Center, Pharmacy Service (119), Memphis, TN 38104. E-mail: firstname.lastname@example.org.
The content in this monograph was developed with the assistance of a medical writer. The authors made substantial contributions to the intellectual content of the articles by conceiving and designing the original presentations, researching references and studies, drafting the manuscripts, reviewing and revising the manuscripts, and/or providing supervision.