Pain management 101 for pharmacists
Special Pain Section
Managing patients with pain can be complex, as patients may have different types of acute or chronic pain and other psychosocial issues. This is an area very familiar to Kathryn Hahn, PharmD, Pharmacy Manager and Pain Management Specialist at Bi-Mart Pharmacy in Springfield, OR. She estimates that approximately 30% of her retail business is managing patients with pain. “Pain patients have a multitude of issues, and it’s not always about opioids,” Hahn said. “We need to better understand how to assess pain symptoms to determine what the appropriate pharmacologic and/or nonpharmacologic interventions may be, and if other alarming patient-specific risk factors may be present.”
“In order to understand the type of pain a patient is having, you need to first start by asking them their symptoms,” Hahn said. Patients should be asked about their specific symptoms so that pharmacists can better determine if the pain is acute or chronic, and how it can be best classified. Patients should be asked about the timing of pain onset, precipitating factors, exact location, activities that make it better or worse, pain rating on a validated scale (e.g., visual analogue scale 0–10), and impact on daily activities and quality of life. Assessing all of these factors will enable the pharmacist to better triage patients and determine whether immediate medical treatment is needed or patients can be adequately treated with OTC or prescription medications.
Chronic pain can be classified into several categories, such as neuropathic, muscular, visceral, inflammatory, or mixed. These types of pain differ in their presentations. For example, patients with neuropathic pain may describe their symptoms as burning, stabbing, throbbing, and/or shooting sensations, whereas those with muscular pain may present with symptoms of tenderness and/or stiffness. Fibromyalgia is a form of musculoskeletal pain in which patients may present with diffuse pain, fatigue, and insomnia. Patients with inflammatory pain from conditions such as osteoarthritis or rheumatoid arthritis may present with swelling, heat, erythema, deformities, and/or loss of function. Understanding the type of pain patients are having will help determine if they are being treated appropriately, according to Hahn.
Appropriate medication selection
Once the symptoms are better understood, pharmacists can then shift their attention to the interventions. “The various types of pain are treated differently, with some interventions not working in select conditions,” Hahn said.
For example, neuropathic pain is not well treated with acetaminophen or NSAIDs. Opioids are only partially effective. Preferred analgesics include tricyclic antidepressants, serotonin–norepinephrine reuptake inhibitors, second-generation anticonvulsants, topical lidocaine, or tramadol.
For musculoskeletal pain, first-line options may include acetaminophen, NSAIDs, or muscle relaxants. For inflammatory pain syndromes, NSAIDs or opioids may be needed for pain control.
“When determining the most appropriate treatment for patients, patient-specific factors must be considered such as patient age, risk for falls, concurrent medications and comorbidities, and risk for abuse and diversion,” Hahn said. “Patients should also be assessed for hyperalgesia and other conditions such as tolerance or dependence.” These conditions will be discussed on page 70.
In addition to pharmacologic interventions, the importance of nonpharmacologic interventions should be addressed with patients. Hahn discussed various interventions such as exercise, physical therapy, aquatic therapy, acupuncture, and psychological modalities, such as cognitive behavioral therapy. “Some conditions, such as fibromyalgia, may derive substantial benefits from lifestyle modifications aimed at reducing pain,” Hahn said.
Role of the pharmacist
“You must look at the whole person and the entire situation when assessing patients presenting with pain,” Hahn said. “You need to get to know them to better understand if they are receiving the appropriate therapies, and if other issues are present and additional follow-up with the provider is needed. Many of these patients have underlying mental health issues that go untreated.”
Pharmacists can establish a strong relationship with long-term patients, Hahn said. “Pharmacists often see chronic pain patients more frequently than the patient’s provider. So this helps them see what is going on, and potentially spot problems—before the prescriber does.”