It takes a village to manage chronic pain: Boots-on-the-ground strategies 


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Special Pain Section
Mary Lynn McPherson, PharmD, MA, BCPS, CPE, Professor, University of Maryland School of Pharmacy, Baltimore

According to a new study conducted by the National Institutes of Health, based on 2012 data, more than 125 million Americans experienced some pain in the 3 months prior to being surveyed. More than 25 million Americans report daily pain, and 23 million Americans report “a lot of pain.”1 Given that pharmacists are probably the most commonly encountered heath professional, it is reasonable to expect pain patients to seek the advice of their pharmacist. Because pain is a subjective experience, it can be difficult to assess and manage. 


A competing public health crisis is that of opioid abuse, misuse, diversion, and overdose deaths. According to the American Society of Addiction Medicine, almost 25 million Americans aged 12 years and older have a history of substance abuse or dependence. In fact, it is estimated that 46 Americans die every day from an overdose, which is approximately two deaths every hour.2 Prescribers have a responsibility to individual patients and society as a whole to appropriately use opioid therapy, but pharmacists also have a corresponding responsibility to assure the appropriate use of controlled substances. September is Pain Awareness Month. This section contains three articles of interest to pharmacists, describing their role in optimizing management for chronic pain sufferers, responsibly dispensing controlled substances, and providing meaningful education regarding pain management and analgesics.


Pain can be categorized several different ways, including the temporal presentation (acute vs. chronic pain), the pathogenesis of the pain (nociceptive vs. neuropathic), or whether it’s cancer-related pain. In the first article on pain management 101 for pharmacists, Kathryn Hahn, PharmD, of Springfield, OR, describes how a pharmacist can perform an assessment of a pain complaint. With any physical complaint, after collecting a history, several courses of action are available to the community pharmacist, including simply reassuring the patient, recommending a nonprescription medication, refilling a prescription medication, recommending a new prescription medication, referring the patient to their primary care provider, or to a more urgent source of care. As Hahn describes, understanding the nature of the patient’s pain complaint helps the pharmacist to determine the most appropriate drug therapy, such as a nonprescription medication for musculoskeletal pain versus an adjuvant analgesic for neuropathic pain.


The management of chronic pain may require use of an opioid analgesic, either as monotherapy or in addition to adjunctive agents, such as antidepressants or anticonvulsants. Pharmacists have a significant responsibility to ensure the appropriate prescribing and use of all controlled substances, but most especially opioids. David Brushwood, BSPharm, JD, provides an overview of VIGIL—a screening process that can be used to determine the legitimacy of a prescription for a controlled substance. Additional useful strategies may include recommending the use of abuse-deterrent opioid formulations, consistent use of a state’s prescription drug monitoring program, working with individual prescribers and patients within the confines of an opioid agreement, and assisting prescribers with interpretation of urine drug screening results.


Most important, pharmacists are tremendous dispensers of information! The final article describes several ways that pharmacists can provide great value in educating patients, prescribers, and others about the safe and effective use of analgesics. For example, patients need to know how to self-monitor and prevent opioid-induced adverse effects, and how to safely store their opioids at home to avoid diversion to an unintended recipient. Increasingly, pharmacists are seeking credentialing as pain educators (e.g., certified pain educator). Credentialing signifies a degree of expertise to colleagues and patients alike.


We are faced with competing public health crises: poorly managed, widespread chronic pain; and opioid misuse, abuse and diversion. Pharmacists are well positioned to have a positive impact on both of these situations.


References


  1. J Pain. 2015;16(8):769–80

  2. www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts...

 

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