Opioids and pain management: Strategies, key points at APhA2016

Controversial opioid issues, physician–pharmacist collaboration among topics of education sessions in Baltimore

APhA2016 in Baltimore included several lively and informative opioid-related education sessions, including Friday’s Point/Counterpoint: Opioids, Overdoses, and Pain Management and Sunday’s Teaming Up for Safer Pain Management Strategies.

Point/Counterpoint: Opioids, Overdoses and Pain Management featured serious debates interspersed with humor between Jeffrey Fudin, PharmD, FCCP, FASHP, DAAPM, and Chris Herndon, PharmD, BCPS, on opioids for chronic noncancer pain and between Tony Tommasello, PD, PhD, FAPhA, and Fudin on increasing naloxone access for opioid overdose. The session was recorded for Meeting Highlights Video on Demand, available later this year.

Fudin, who is clinical pharmacy specialist and postgraduate year 2 pain residency director at Stratton VA Medical Center, said strategies that enhance safe use of chronic opioid therapy include the following:

  • Encourage the use of risk stratification tools.
  • Education for all prescribers and pharmacists
  • Slow escalation of opioid doses upon conversion
  • Recognize unique population variables.
  • Realize the value of a pharmacist “provider” to mitigate drug risks.

Herndon’s title slide for his side of this debate was “Here’s some oxycodone for your hangnail.” He is associate professor at Southern Illinois University. He described the controversial CDC opioid prescribing draft guidelines as common sense. “They’re not saying don’t do it. All they’re saying is stop and think,” he said.

Fudin said, “If you’re going to use opioids for nonchronic cancer pain, you need to be smart about it.”

Tommasello, who is medical science and treatment advisor for RBP Solutions, summarized his position on naloxone access as follows:

  • Naloxone is a time-tested proven antidote for opioid overdose.
  • Intranasal insufflation is an efficacious means of naloxone administration.
  • The number of opioid overdoses is increasing for a variety of reasons.
  • Overdose education and naloxone distribution can reduce opioid overdose events.

Fudin said that pitfalls of outpatient naloxone included knowing what is being dispensed and if it works, payment for product and prior approval, payment for counseling, and liability.

In Teaming Up for Safer Pain Management Strategies, Fudin and Lynn Webster, MD, presented on collaboration between prescribers and pharmacists to minimize opioid misuse and abuse while ensuring that patients with legitimate needs have access to opioids.

“I’ve always felt very close to pharmacists because I have truly felt they are my partner,” said Webster, vice president of scientific affairs for PRA Health Sciences and past president of the American Academy of Pain Medicine.

Most pharmacists whom he has known “knew more about drug interactions than physicians,” Webster added. He said he’d love to have the ability to have the pharmacist there to do most of the drug management.

The pharmacist enhances patient care, according to Webster, “but our challenge is we can’t reimburse for the pharmacist’s time.” He added that having a pharmacist was “always a loss leader.”

Fudin asked Webster, “If a pharmacist could be reimbursed, would you get the pharmacist in the [physician’s] office?”

“Yeah, I think that’s where we’re moving,” Webster replied.

For Webster, barriers to physician–pharmacist collaboration included reimbursement and sufficient time, and the egos of the physician and the pharmacist.

Key points in the education session included the following:

  • Converting from one opioid to another may not be based on a simple mathematical model.
  • Methadone is an extremely dangerous drug if dosed by an inexperienced clinician.
  • Pharmacists have an important collaborative role with physicians and other prescribers.
  • Pharmacists have a corresponding responsibility with the prescriber when dispensing opioids.
  • Physicians, nonphysician prescribers, and pharmacists play an important role in patient monitoring, counseling, and overall safety.

The education session was interactive. When a case study was presented, pharmacist after pharmacist came up to the microphone in the middle of the crowded room to say what they would do. At one point, a line formed at the microphone.

One pharmacist said her biggest challenge was the lack of documentation and communication from the prescriber to the community pharmacist.

Webster advised attendees, “First and foremost, you have to have a relationship.” Pharmacists need to feel the physician would pick up the phone if they called; that they could be honest with the physician.