Many students graduate with an understanding of which drugs are used in pain management, their side effects and the risks associated with long term use. While this basic information is valuable to any pharmacy student, many lose or never acquire a grasp of the more patient specific information such as what dose/duration of an opiate is appropriate for a patient given their unique condition and degree of opioid tolerance. Many are unfamiliar with the efficacy and appropriateness of SNRI’s in treating neuropathic pain. These more refined concepts equip students with the tools to recognize impractical dose titrations, make responsible adjustments to institutional formularies and answer practitioner questions about alternative therapeutic options.
Of the seven pharmacy schools active in New York State, two offer pain management elective courses to their students. Wegman’s School of Pharmacy at Saint John Fisher College offers a 2 credit graduate level course titled Pain and Palliative Care. The course catalog proposes a learning experience focused on clinical care and synergistic relations with other practitioners:
“Pain and palliative care are emerging areas of pharmacy practice. This course will provide students a detailed understanding of pain and symptom management treatments for patients with advanced illness. Students will also learn methods to communicate and provide pharmaceutical care to pain and palliative care patients, caregivers, and interdisciplinary team members.”
In the past year, Dr. Jeffrey Fudin introduced a 3 credit graduate elective at Albany College of Pharmacy and Health Sciences; appropriately titled Pain Management Pharmacotherapy. His course focuses on implementing class lectures and published literature to evaluate complex patient cases. Classes also feature guest speakers which include a variety of specialists active within the pain management arena.
Instilling within students a strong focus on the transitioning of patient care is an essential puzzle piece needed to stem the rise of opioid related deaths while ensuring adequate pain management. Many patients receive insufficient palliative care due to overly-prudent practitioners and fearful patients who shy from opioid use because of the stigma associated with opioid use. In the past several years, the news has been littered with stories of drug addicts holding up and sometimes murdering pharmacists at gunpoint in order to get their hands on the drugs they needed to ease/avoid withdrawal symptoms. In publicizing efforts to counter these crimes, a new wave of legislation and drug monitoring programs has emerged into the public eye. The Internet System for Tracking Over-Prescribing (I-STOP) Act will deploy an online controlled substance reporting system within New York State that requires prescribers and pharmacists to report certain data at the time a controlled substance is issued and when dispensed. This is a great step forward toward tracking and potentially mitigating the ongoing drug diversion.
Recently, a friend of mine told me that he was afraid of being prescribed hydrocodone to deal with the pain he would soon anticipate following a scheduled removal of his wisdom teeth. He did not want to risk becoming an addict. This degree of fear is preposterous. Stepping up efforts to control the flow of opioids could yield success in thwarting criminals and “Dr. Shoppers” but awareness of these efforts needs to be managed differently. New policies could instead be presented to healthcare practitioners in the classroom setting (i.e. a pain management course), as a continuing education activity, pain certifications, and should be encouraged by healthcare employers from every discipline. Attention to this problem may help to ensure more adequate pain management for those in need and could help to minimize potential harm incurred by unsuspecting patients who might otherwise turn to heavy NSAID and/or acetaminophen use because their fear of opioid addiction irrationally outweighs their fear (or knowledge of) GI ulceration, hepatotoxicity and/or renal failure.
Generating fanfare over these new efforts may provide shallow reassurance to a portion of the population, but it ultimately discourages patients from seeking/accepting the care that they need. By educating healthcare practitioners with more course options focused on pain/palliative care, and by keeping informed within the medical scene, perhaps we can work as a team to solve the growing drug abuse epidemic without compromising patient care.
Greg Tompkins
Pharm.D. Candidate, 2013
Albany College of Pharmacy Health Sciences
Congratulations to Greg and Dr. Fudin for this information!
I’m an ACP 1961 graduate (ancient, I know, and before the “HS” was added to the school name) practicing nuclear pharmacy in Kentucky. The Bluegrass State has a huge drug-abuse problem, with home-grown methamphetaime labs a cottage industry. The state legislature passed emergency legislation this summer (House Bill 1) to address the issue. Physicians, nurses, and pharmacists in the state are now meeting with legislators to learn if treating their next patient will land the practitioners in jail due to the particular wording of the legislation. That could be coming to a state near you.
John,
Thank you for your comments and nice to hear from an ACP alumni!
FYI, you may want to see Dr. Murphy’s (from your neck of the woods) comment (on another one of my blogs) and reply. It is at https://paindr.com/label-changes-for-opioids-for-or-against/ and I pasted it below too.
James Patrick Murphy, MD
August 9, 2012 at 12:58 PM
I am a Pain Specialist in Kentucky, so I speak to you from the front line in this battle. Our “leaders” recently enacted our country’s most far-reaching and intrusive pain regulations to date (http://kbml.ky.gov/House+Bill+1+Emergency+Regulation) . These laws were passed in a politically expedient manner with the media gleefully trashing the Kentucky Medical Association and our KMA President (by name), going so far as to say he was turning his back on his Hippocratic Oath and harming people by not supporting the pain bill.
I know of and am personally acquainted with many of the signees of the PROP petition. I respect them all. But I want to caution against any medical expert providing ammunition or “cover” to politicians hungry to emerge as a “champion” against drug abuse. It is a “siren’s song” that will lead to destruction on the rocky shore (i.e. Kentucky’s current situation). There are plenty of cheers (and votes) to be had when one can claim he or she has done something to stop drug abuse. But as the politicians are beating their chests, and saying “Look what I did” no one speaks for the silent sufferers, the downtrodden and shame-filled innocent people suffering with legitimate unrelenting pain.
We must speak for them. If not us, then who? If not now, then when?
I hope the PROP faction will reconsider their petition and be inclusive of the wide range of people who have a stake in this issue.
This reflection on the perception of pain management drugs, and opiates in particular, is especially prescient for the treatment and management of psychiatric clients. Often times these patients also experience significant pain issues. Prescribers in institutional settings are generally reluctant to recommend pain management drugs when the prevailing symptoms are mental health issues. It would seem that this stance is harmful to patients who may experience increased psychiatric symptoms due to a very real physical pain. It is certainly an area for further examination.
Fear associated with opiates is common. Both friends and family alike express their disdain for opiates because they are “for junkies” and that they are above the use of narcotic painkillers. Often, the result is a less pleasant recovery relying solely on acetaminophen, which has it’s own slew of (acute) side effects when used inappropriately. I think the fear of opiates needs to be moderated somewhat as opiates, when used correctly, are some of the safest drugs we have as practitioners. The same cannot be said of APAP/NSAIDs, but the addiction potential is not there.
Opiates need to be utilized more effectively, neuropathic pain needs to be recognized for what it is, and treated as appropriately, and opiate management needs to be strict. Patients should be using their medications as written, no less and no more. And unless all members of the healthcare team are on the same page in terms of pain management, the pharmacist, physician, patient or patients family may not see eye to eye on treatment, and any one of them may act as a barrier to care.
Joe, Thank you fit your insightful comments. It’s nice to see student pharmacists taking such a keen interest in pain management.
What an insightful post, Greg. This brings up an emerging obstacle for the healthcare field. The nation’s high number of prescription drug abuse cannot solely be blamed on the patients. We, as healthcare professionals, should be held more accountable, as a good proportion of those abusers are getting their “stash” due to legitimate prescriptions and prescribing carelessness.
It is unnerving to see that a pain medication is of the highest prescribed in the United States, yet pharmacy schools utilize minimal mandatory classroom time to cover this extremely important topic. In the future, pharmacy, medical, and all healthcare schools alike should hit on this topic in more depth for their future graduates.
Sarah, I believe your comments are spot on. Thank you!