Pain Management
Loren Bonner
As Thomas Franko, PharmD, BCACP, associate professor of pharmacy practice at Wilkes University in Pennsylvania, put it: “The more information we know about appropriate pain management, the better.”
New CDC data show that approximately 20% of U.S. adults reported experiencing chronic pain in 2019.
With COVID-19 dominating the news this year, equally important topics—like pain management—may have gotten buried. This article includes important updates for pharmacists and other clinicians on pain management.
Label changes for benzodiazepines
In late September, FDA announced that it is requiring an update to the boxed warning of benzodiazepines and is issuing class-wide labeling changes to include the risks of abuse, misuse, addiction, physical dependence, and withdrawal reactions.
Benzodiazepines are commonly abused and misused and can be especially dangerous when taken with opioids. According to FDA, an estimated 92 million benzodiazepine prescriptions were dispensed in U.S. outpatient pharmacies last year. About 50% of oral benzodiazepines dispensed in 2018 were for a duration of 2 months or more. Studies indicate that using opioids and benzodiazepines at the same time can increase the risk of death from overdose 10-fold. According to the National Institute on Drug Abuse, 23% of individuals who died of an opioid overdose in 2015 also tested positive for benzodiazepines. In its drug safety communication, FDA said it is also requiring additional changes to the warnings and precautions, drug abuse and dependence, and patient counseling information sections of the prescribing information for all benzodiazepines. FDA is requiring revisions to the existing patient medication guides for these products to help educate patients and caregivers about the risks.
FDA warns about gabapentin
FDA issued a warning on the risks of gabapentin misuse and toxicity, particularly in combination with opioids. In a safety communication, FDA warned about breathing difficulties for patients who have respiratory risk factors and asked that new warnings be added to the prescribing information for gabapentinoids.
Gabapentin is recognized as a first-line agent for treatment of neuropathic pain, and many health care providers have embraced it as a safer alternative to opioids for pain management. The Drug Enforcement Administration has not classified gabapentin as a controlled substance, but some individual states have made the anticonvulsant a Schedule V controlled substance.
FDA said patients should be started on the lowest dose of a gabapentinoid, and health professionals should monitor patients for symptoms of respiratory depression and sedation when co-prescribing gabapentinoids with an opioid or other central nervous system depressant, such as a benzodiazepine.
Patients with underlying respiratory disease and older adult patients are at an increased risk.
Pain management in the COVID-19 era
The pandemic has affected how clinicians have been treating pain and how patients are faring overall. Like most health care practices during this time, those that specialize in pain have been seeing their patients via telehealth for appointments.
Franko from Wilkes University, who counsels many older adult patients with chronic pain, said he’s not only seeing them virtually but also is encouraging them to stay active at home through online tai chi videos and such.
“We are trying to treat function, not get [chronic pain] down to zero,” said Franko. The goal is to make sure the individual can function and get around their home.
“It’s a condition we can’t cure, but with adequate lifestyle modification [and appropriate medication], we can effectively treat it,” said Franko.
Clinicians need to remind patients that treating pain is never a quick fix. It normally involves addressing emotional as well as physical pain—which is especially important right now during the pandemic, as many pain patients are experiencing added loss and anxiety.
Franko said pharmacists in the community setting can always consider doing a proper pain assessment using the PQRST pain assessment method (P = provocation/palliation, Q = quality/quantity, R = region/radiation, S = severity scale, and T = timing) and can also serve as a coordinator of care for patients.
“ ‘How do you feel emotionally? Did you go to physical therapy?’ You can ask those kinds of questions and make those recommendations for treatment,” said Franko. “As community pharmacists, we see our patients often and know them well. We can leverage that personal connection to help them and be a social support help for them.
New opioid resource available for pharmacists and technicians
APhA has teamed up with Walmart to offer a free online training program on opioid stewardship to all pharmacists and pharmacy technicians in the United States.
The training provides many tools and tips for conversations and counseling that pharmacists can use with their patients on a daily basis.
Jonathan Stewart, PharmD, pharmacy clinical services manager at Walmart, said one of the biggest takeaways he received from the training was about the difference pharmacists can make through simple interventions—whether it’s with naloxone or by having a caring, candid conversation with a patient.
“There are a lot of ways to discuss naloxone with patients,” said Simone Ginn, RPh, pharmacy clinical services manager at Walmart, who participated in the training. “I learned that it is not a ‘one size fits all’ discussion. I find patients trust me and are more likely to get the naloxone when the conversation has empathy and is not just something that needs to be checked off a to-do list.”
Stewart said he also uses the training to interact with prescribers collaboratively.
The customized pharmacist program contains 6.5 hours of training and education, including a pain management curriculum.
The online training program was originally developed in 2018 for Walmart and Sam’s Club pharmacists. Through an unrestricted educational grant provided to APhA by Walmart, the program is now available free to all pharmacists in the United States as parts of the country contend with increased opioid-related overdoses and access to social and treatment networks is disrupted by the COVID-19 pandemic.
“Education is priceless,” said Ginn. “The more knowledge we have on pain management, the more likely we will be ready and able to engage with patients.”
NSAIDs should be used as first-line therapy for acute musculoskeletal pain, groups say
A new guideline from the American College of Physicians and the American Academy of Family Physicians calls for topical NSAIDs to be used as a first-line treatment for acute pain lasting no more than 4 weeks from musculoskeletal injuries that do not involve the lower back.
Based on the most up-to-date evidence about benefits and harms, the guideline recommends topical NSAIDs with or without methanol gel. Data show that topical NSAIDs improve not only pain for these types of injuries, but also patients’ physical function and treatment satisfaction.
The guideline, published in Annals of Internal Medicine, also recommends use of the following:
- Oral NSAIDs to improve pain and physical function, or oral acetaminophen to alleviate pain
- Specific acupressure to improve pain and physical function, or transcutaneous electrical nerve stimulation to reduce pain
- Opioids, including tramadol, to treat such pain
The guideline does not address noninvasive treatment of low back pain.
Recommendations were based on a network meta-analysis of more than 200 trials with roughly 33,000 patients using the Grading of Recommendations Assessment, Development, and Evaluation methodology.