The Pharmacist's Role in Palliative Care and Chronic Pain Management
Meyers, John C, Drug Topics
By definition, to palliate means to "relieve or lessen without cure." Palliative care, therefore, implies a treatment goal of making the patient comfortable, not curing the
disease. While the transition to palliative care is defined and accepted to a greater degree in oncology and in the treatment of AIDS, it is appropriate in most chronic diseases near the end of life.
Transitions occur throughout the treatment of long-term diseases such as cancer. Initially, the treatment goal is to cure the cancer or to secure a long-term remission. If the cancer recurs, the goal may be to put the cancer back into remission, knowing that a cure is unlikely. As the process continues, there may come a point where significant remission is unlikely and the quality of the patient's remaining life is adversely affected by additional cancer treatment. It is at this juncture that a move to palliative care should be considered.
The transition to palliative care is an important decision. With palliative care, the physician is setting a treatment goal that is attainable--patient comfort. Although physicians, patients, and the family may feel that "nothing else can be
done," palliative care can still be provided, and this may be the most important treatment to the patient at this point. During active treatment, the disease may be battled aggressively--with the hope of cure or significant remission taking precedence over patient comfort. In palliative medicine, however, the entire focus of attention is on the comfort of the patient.
Pain management has received the most attention in palliative care. The pharmacist's
role in palliative care is so important that some boards of pharmacy have distributed guidelines encouraging pharmacists to become actively involved in terminal care. Guidelines from the pharmacy boards demonstrate their desire to eliminate the barriers that the boards themselves have imposed. The following is an example of guidelines issued by the California State Board of Pharmacy:
DISPENSING CONTROLLED SUBSTANCES FOR PAIN
The pharmacist's role (as educator and as manager) in providing drug therapy for patients in pain is extensive. The responsibilities that pharmacists must fulfill if they are to provide complete pain management service include:
1. Facilitate the dispensing of legitimate prescriptions.
2. Understand and learn about the effective uses of all pain medications, especially opioids and other controlled substances, in the management of pain.
3. Carefully explain dosage regimens and discuss potential side effects of pain medications.
4. Monitor and assess the patient for effective pain therapy
outcomes, evaluate compliance, assess for tolerance to opioids, and ensure subsequent dosage adjustments as needed.
5. Obtain, retain, and update appropriate information documenting the course of and need for ongoing opioid therapy.
6. Encourage patients to talk with their pharmacist about their medications--the benefits and problems.
7. Discuss and allay the patient's possible
fear of addiction with the use of narcotics, where this is a factor.
8. Watch for patients who misuse their prescriptions, and be especially aware of a patient or family history of substance abuse that might complicate pain management, and act accordingly.
9. Assess the patient for adverse drug reactions from the pain therapy regimen, and take action to minimize or eliminate them.
10. Be aware of and recommend nonmedication treatments for pain or refer patients for such when appropriate.
11. Evaluate OTC drugs, Rx drugs, and alcohol, taken with pain medications, for potential drug interactions.
12. Recognize that patients and caregivers are important sources of information in assessing the patient's pain therapy.
13. Act as liaison between patients and other health-care providers, ensuring open communication and understanding about the drugs patients are taking to reduce pain. …