Managing patients with pain requires a lot of education of both patients and providers. Patients need to understand the type of pain they have, how to appropriately use medications to maximize benefits and minimize risks, and pain-related issues such as physical dependence, tolerance, and hyperalgesia. Providers such as pharmacists and prescribers also can benefit from education on pain principles to more appropriately manage their patients.
As noted on page 66, pain management can be complex, and use of opioids can be especially complex as it may result in states of physical dependence, tolerance, or hyperalgesia.
Physical dependence is a state of adaptation that can result in class-specific withdrawal symptoms if the drug is abruptly stopped, or if the dose is reduced too quickly. Therefore, patients who have developed dependence to the pain medication must be managed carefully to avoid withdrawal symptoms. With both tolerance and opioid-induced hyperalgesia, patients may have uncontrolled pain and require further dose escalations. The two conditions differ, however, in that tolerant patients generally obtain pain relief with escalating doses, whereas patients with hyperalgesia may actually experience more pain. Therefore, having a solid understanding of what is going on with the patient and his or her condition can better determine how he or she should be appropriately managed.
Opioids are one of the most commonly used medication classes to treat pain. This class of drugs is effective if used appropriately, but patients need to understand proper dosing and potential adverse effects. In addition, pharmacists need to be vigilant for potential drug–drug interactions and signs of abuse or misuse.
When dispensing a prescription for an opioid, some key topics need to be covered with patients, such as proper dosing; potential adverse events and risks; and safe handling, storage, and disposal. Patients should understand the amount of medication that has been prescribed to them, and that if too much is taken, they can easily overdose and have serious adverse events, including death. Patients should also understand the most common adverse events reported with opioid use, which are generally gastrointestinal or related to the central nervous system (CNS). Common events include constipation, nausea, vomiting, somnolence, fatigue, and dizziness. Pharmacists should educate patients on opioid-induced constipation and recommend an appropriate bowel regimen to counteract this problem (e.g., a stimulant laxative or polyethylene glycol). In addition, all patients should be given the FDA-approved Medication Guide, and these guides should be reviewed with patients at the time of dispensing.
When assessing opioid prescriptions, pharmacists should be vigilant for potential drug–drug interactions that may have an additive effect when combined with opioids, such as use of other CNS depressants (e.g., benzodiazepines). In addition, pharmacists should screen prescriptions carefully and talk to patients using chronic opioids to assess for any potential signs of misuse, abuse, or diversion (see page 69).
In addition to proper use and potential adverse events, pharmacists must educate patients on safe use and handling of their pain medications, especially opioids. Following are some tips for patients:
This article only touches upon the many issues that patients with pain encounter and on the education that is needed to keep them—and the ones close to them—safe. Pharmacists interested in getting more education or becoming a certified pain educator or credentialed in pain management can obtain more information from organizations such as the American Society of Pain Educators (www.paineducators.org) or the American Academy of Pain Management (www.aapainmanage.org).