Acute Pain Management and Opioid Treatment: Community Pharmacist Perspectives
Brien L. Neudeck, PharmD*
Acute pain is one of the most common medical conditions encountered by pharmacists and other healthcare professionals. More than 70 million people undergo surgical procedures each year in the United States, and approximately 80% of these patients experience acute postoperative pain.1 Pain is also common among patients with musculoskeletal injuries, dental procedures, cancer, headache, during labor and delivery, and from numerous other causes. There are nearly 100 million physician office visits for acute injuries each year in the United States, and pain relievers are the second most commonly prescribed class of medications, following only cardiac-renal drugs.2 Several studies have demonstrated the undertreatment of acute pain following surgery and in other settings,3 and a recent nationwide survey conducted by the National Pain Foundation found that many adults who experience acute pain are reluctant to seek treatment or use prescription medications.4,5 This survey found that out of a total of 1484 adults questioned, 27% reported that they experienced at least 1 episode of acute pain lasting longer than 24 hours during the preceding 12 months, but that only 30% of these individuals saw a physician. Many of the survey participants thought that their physician could not help to relieve their pain, or they were unwilling to use medications due to the risk of gastrointestinal discomfort or other adverse effects.
Opioid analgesics are powerful tools for the treatment of moderate-to-severe acute pain, yet several obstacles prevent the effective management of pain for many patients. Although the risk of addiction is a common concern among patients and many clinicians, a large body of evidence suggests that addiction is very unlikely when opioids are used for the treatment of acute pain by patients who do not have substance abuse disorders.6 Other obstacles include relatively limited education about pain management on the part of many healthcare professionals, government regulations regarding the use of opioid medications, and inadequate assessment of the severity of acute pain.7,8 Control of acute pain is important to relieve patient discomfort, but also to reduce the risk of chronic pain. Untreated acute pain and inflammation associated with tissue injury can cause long-term structural alterations of pain pathways within the central nervous system, resulting in the transformation to persistent chronic pain.9 Several studies have shown that patients who do not attain adequate relief following surgical procedures or other forms of acute pain are at greater risk of developing chronic pain.10,11 Untreated pain is also associated with a slower rate of recovery and increased utilization of healthcare resources.12
Community pharmacists are often the first point of contact for patients with questions about pain or pain therapy. Given their extensive training and expertise, pharmacists are valuable resources for patients with a variety of painful conditions, providing education about drug administration, side effects, and the potential for drug interactions. Continuing education about current standards of pain management is therefore essential for community pharmacists. In addition, new opioid medications and delivery methods frequently enter clinical practice. Recently developed formulations or delivery systems of established medications for acute pain include the administration of fentanyl using patient-controlled transdermal patches or oral transmucosal tablets, a novel transdermal hydromorphone patch, and a recently developed sublingual sufentanil formulation (sufentanil nanotabs), among others. The novel opioid pain reliever tapentadol, which acts at m opioid receptors and also increases central noradrenergic activity, is in the late stages of clinical testing for acute and chronic pain, and other new opioid analgesics are being developed.
This issue of University of Tennessee Advanced Studies in Pharmacy provides community pharmacists with an overview and update on the use of opioids for acute pain management. Kathryn Hahh, PharmD, discusses the initial assessment of acute pain, the pharmacology of opioid analgesics, factors that influence the selection of a particular opioid for acute pain, the use of combination therapy, and novel analgesic agents and formulations for acute pain. Scott A. Strassels, PharmD, PhD, BCPS, describes the risk of addiction and dependence when opioid analgesics are used for acute pain relief. Dr Strassels reviews the results of several clinical studies demonstrating that the risk of addiction is extremely low when opioids are used for acute pain treatment, and that inadequate treatment of acute pain is a significant predictor of chronic pain and other undesirable health outcomes. The monograph concludes with a review of management strategies for opioid-induced adverse effects by Mary Lynn McPherson, PharmD, BCPS, CDE. Dr McPherson also discusses the importance of monitoring treatment efficacy and safety using both objective and subjective assessments.
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*Associate Professor, Departments of Pharmacy and Pharmaceutical Sciences, University of Tennessee College of Pharmacy, Memphis, Tennessee. Address correspondence to: Brien Neudeck, PharmD, Associate Professor, Department of Pharmaceutical Sciences, University of Tennessee College of Pharmacy, 847 Monroe Avenue, Suite 227A, Memphis, TN 38163.
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