Pain Management for Pharmacists: Concepts and Definitions
Kubotera, Natsuki, Fudin, Jeffrey, Drug Topics
Pain and related symptom management involve complex polypharmacy, a keen understanding of pharmacotherapeutics, and interdisciplinary collaboration. This is the first in a series of pharmacist continuing education articles dedicated to pain management. Primary literature from pharmacy, medicine, and nursing recognize an inadequate time commitment to pain management and appropriate medication therapy. This, coupled with the necessary balance required for chronic opioid therapy, has become a therapeutic, political, and legal conundrum especially for prescribers and pharmacists. Epidemiologic and prevalence data for acute and chronic pain are reviewed along with recent FDA developments and associated regulatory debates. An overview of the pharmacist's role in pain and palliative care and the developing specialty practice in pain management are chronologically presented. Common medical terminology, pain pathophysiology, and descriptive pain types demarcated with respect to acute, chronic, nociceptive, visceral, somatic, and neuropathic pain are reviewed. Physical findings such as dysesthesia, parathesia, allodynia, hyperalgesia, and hyperpathia are differentiated, and appropriate medications by pharmacotherapeutic class are outlined. Opportunities for medication therapy management, responsibilities for the pharmacist provider, and the key role that pharmacists can provide for quality pain management outcomes are identified.
Pain and related symptom management often involves complex polypharmacy, a keen understanding of pharmacotherapeutics across several drug classes, and collaboration with other healthcare disciplines. Undoubtedly the time commitment to pain management education for entry-level graduates within schools of pharmacy, medicine, and nursing is lacking.1 Given that most complex pain syndromes and palliative symptom management involve medications such as opioids, gastrointestinal (Gl) agents, antidepressants, anticonvulsants, skeletal muscle relaxants, and other medication classes alone or combined for purposes of pain management and other comorbid conditions, it is incumbent on pharmacists to seek professional advancement in pain management and secure a comprehensive role as interdisciplinary healthcare team members in all practice settings. Perhaps most compelling is that even with numerous evidence-based pain practice guidelines in place, patients continue to suffer needlessly, outcomes overall are poor, and society pays a high price figuratively and practically through absenteeism, presenteeism (present at work under suboptimal health conditions), and costs of suboptimal treatment strategies, resultant clinic and emergency department (ED) visits, hospital admissions, and readmissions.1-4
Chronic pain affects 100 million people in the U.S. and is the most common reason that patients visit healthcare practitioners, the leading cause of disability, and comes with a price tag of $560 to $635 billion per year.5 An estimated 20% of adults (42 million) report that pain or physical discomfort disrupts their sleep several nights per week.5
In 2006, 46 and 35 million inpatient and ambulatory surgeries, respectively, were performed in the U.S.6·7 In a national survey sampling 129 hospitalized surgical patients, 88% reported moderate, severe, or extreme pain on hospital discharge.8 In 2006, the Multum Lexicon database began collecting drug data for emergency rooms, and during that first year the most commonly prescribed drug classes for each visit included opioid analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) (collectively 36.8%).9 According to the National Hospital Ambulatory Medical Care 2009 Emergency Department Summary from the Centers for Disease Control and Prevention (CDC), 5 of the 10 leading principal reasons for ED visits included acute pain.10
Aside from the practical therapeutic reasons, federal and state governments have sought to more closely scrutinize and regulate opioids through prescription monitoring programs and nonvalidated opioid dose limitations to address increased deaths from opioid abuse. …