Okay, certainly not all physicians (NPs, PAs) dread it and for sure not all pharmacists dream of it. But it is clear that PCPs treat the majority of pain and those medical practices that specialize in pain, more often than not, choose to focus on interventions and healthy lifestyle changes (a wonderful thing) while avoiding medication management.
Upshur and colleagues surveyed over 100 providers including attendings, residents, and nurse practitioners (NPs)/physician assistants (PAs) in “Primary Care Provider Concerns about Management of Chronic Pain in Community Clinic Populations”. They reported that almost 40% of all office visits in the primary care setting were typically for chronic pain. Respondents “… attributed problems with pain care and opioid prescribing more often to patient-related factors such as lack of self-management, and potential for abuse of medication than to provider or practice system factors. Nevertheless, respondents reported inadequate training for, and low satisfaction with, delivering chronic pain treatment.”
In 2009, Dr. Bill McCarberg eloquently pointed out in a Medscape article that “Moderate to severe pain is still one of the most common reasons for primary care visits in the United States. In a 2008 survey, more than 1 in 4 Americans reported an episode of pain during the previous year.” “Pain remains undertreated, especially in the primary care setting. Even when patients make the decision to visit a healthcare professional, inadequate training and resources may prevent proper assessment of their condition. Deficiencies in pain management related to patient gender, race, and socioeconomic status have been reported.
While the government has spent millions of dollars on the “war on drugs”,REMS (Risk Evaluation and mitigation strategies), and the “opioid epidemic”, the possibility of encouraging collaboration with clinical pharmacists in primary care and/or pain practices has not been suggested or considered as an option to mitigate the “opioid epidemic” and other toxic drug outcomes to improve safety, patient outcomes and lessen the stress on providers. I suspect that is because professional pharmacy organizations may not have prioritized the potential impact in this specialty area. Nevertheless, this Executive Summary, Background and Recommendations; Strategic Planning Summit for the Advancement of Pain and Palliative Care Pharmacy nicely delineates where we’ve been and where we need to go in terms of training and education for pharmacy clinicians.
I would venture to guess that most prescribers have not ever worked with a clinical pharmacist in an outpatient setting and even fewer have collaborated with one that has particular expertise in pain management. If you don’t know what you’re missing, it would never enter your mind that this could potentially alleviate a huge burden, improve patient outcomes, and reduce liability.
The problem of incorporating clinical pharmacy pain specialists into primary care and pain practices, as I see it, is lack of pharmacist clinicians to go around. The reason for this is quite simple. Congress has not yet recognized clinical pharmacists as “providers” and therefore practices cannot bill for patient visits the same way they can for a physician, NP, PA, or even a midwife. It is downright ludicrous! There is a nice overview of this issue and the proposed Congressional Bill in Pharmacy Times, located here. On the other hand, the Departments of Veterans Affairs and Defense have been employing clinical pharmacy specialists for many years in areas such as primary care, infectious disease, heme/onc, psychiatry, nephrology, hepatology, and many more. In these clinics, pharmacists see patients that are receiving rational (or irrational) polypharmacy and are prescribing/adjusting their medications, ordering/monitoring their lab work, and collaborating with the patients’ medical specialist routinely. When an unexpected new medical finding arises, the responsible medical clinician evaluates the new finding and intervenes.
So here’s the thing…
For primary care and pain specialty clinicians, the prospect of treating pain with medications often remains a complex, perhaps daunting encounter that requires lengthy visits, careful attention, and very high liability for over- or under-treating pain. Physicians often DREAD it, but clinical pharmacists DREAM of it. Appropriate care involves close urine monitoring and perhaps serum monitoring, and also careful attention to accurately interpreting the results. One must also be aware of dangerous drug outcomes, some of which are monitored by various chemistries, interactions including those with herbal supplements, vitamins products, and the like. Below in festive orange is a list of some of the activities for which a medical clinician can rely upon the clinical pharmacy pain specialist.
As Collaborative Drug Therapy Management develops within New York State, the State Board of Pharmacy asked for medical providers to come forward in support of such services. The 2014 “Report to the New York State Legislature, The Impact of Pharmacist-Physician Collaboration on Medication-related Outcomes” is located here. It contains substantial positive feedback from primary care and specialty clinic providers that have worked with clinical pharmacy pain specialists at our local VA Medical Center.
Young pharmacists DREAM of working side-by-side with medical providers and taking care of patients after training for many years and incurring student loan debt. They are motivated and highly qualified with post-Pharm.D. residency and fellowship training, but jobs are lacking and competitive, and more often than not, mostly available in collaboration with academic or government institutions –this has to stop! Clinical Pharmacist services should be the norm, not just for entitled or academic medical facilities. These people need to be recognized for their clinical expertise and paid for it and it should be the standard of practice in HIGH RISK populations such as pain management!
So I ask our medical and pharmacy colleagues, can you imagine a world in which pharmacists were part of a clinical outpatient (or inpatient) team whereby the pharmacist oversees the necessary tasks for monitoring and prescribing pain medications? For that to happen, Congress needs to get off the stick and approve this Bill ASAP. More importantly, they should be funding training programs to encourage more Pharmacy Pain Residency programs, as there are only eleven in the entire country. We should all be working together to improve patient outcomes, to give patients the time and care they deserve for medication management, to help medical providers, and to pay pharmacists for these much needed services.
I would love to see comments from medical doctors (NPs, PAs) that have worked with clinic pharmacists, and of course those that have not but welcome it. I would also like to see comments from pharmacists that have undergone intensive training in the area of pain management to share experiences, and other pharmacy specialists that are underutilized because of reimbursement issues and their lack of “provider status” as defined by Congress and not reimbursed by third party insurance payers. This country lacks the providers necessary to care for pain patients and there is a shortage of primary care providers. Clinical pharmacists won’t be the only answer, but my goodness, they DREAM of doing this – let them do it!
SPECIFIC PAIN RELATED ACTIVITIES INCLUDE:
- Comprehensive analgesic pain medication evaluation including all medication therapies but with a focus on analgesic therapies and potential drug interactions.
- Medication history review and reconciliation
- Initiation, modify and/or recommend medication regimens as allowable by current regulation
- Assessment of adherence to medications
- Risk assessments evaluations and documentation with validated tools and lab analysis
- Urine Drug Test evaluations
- Immune Assay
- Qualitative Testing (gas or liquid chromatography mass spectrometry (GC-LCMS)
- Adulteration Behavior Checks (ABC) and Specimen Validity Testing (SVT)
- Behavior modification techniques and follow-up services for nonadherence
- Pharmacokinetic and clinical monitoring of medications
- Pharmacogenetic testing and interpretation of results
- Patient education regarding self-administration and monitoring of medications
- Monitoring for therapeutic effects, drug interactions, and adverse drug events through drug regimen review, laboratory data/vital sign assessment and patient interview
- Identification of and monitoring for behaviors of medication misuse, abuse, and/or addiction
- Assist with the development of clinical protocols to encourage the systematic approach to and use of various analgesic therapies
- Provide educational conferences to staff and affiliates on topics related to pain pharmacotherapy
- Conduct academic-detailing and/or drug use evaluations and respective outcomes
- Assist with quality improvement projects to improve processes related to patient care
Competency for position includes
- Chronic pain syndromes
- Pain pharmacotherapy
- Knowledge of interventional therapies
- Risk assessment and management
- Toxicology and urine drug screening evaluation
- Responsible opioid prescribing/universal precautions
- Behavioral interventions
- Motivational interviewing
- Addiction medicine
- Inter-professional communication and collaboration
- Referrals when appropriate
- Prescribe medications
CLINICAL PHARMACIST IN PAIN MANAGEMENT, GENERAL FUNCTIONS AND SCOPE OF PRACTICE
- Conduct comprehensive appraisals of patients’ health status by taking health and drug histories. Relevant findings must be documented in the patient’s medical record.
- Evaluate drug therapy through direct patient care involvement, with clinical assessment and objective findings relating to patient’s responses to drug therapy and communicating and documenting those findings and recommendations to appropriate individuals and in appropriate records (i.e., patient’s medical record).
- Develop and document therapeutic plans utilizing the most effective, least toxic, and most economical medication treatments.
- Provide patient and health care professional education.
- Order, perform, review, and analyze appropriate laboratory tests and other diagnostic studies necessary to monitor and support the patient’s drug therapy.
- Perform the physical measurements necessary to ensure the patients appropriate clinical responses to drug therapy.
- Assist in the management of medical emergencies, adverse drug reactions, and acute and chronic disease states.
- Identify and take specific corrective action for drug-induced problems.
- Order consults ON BEHALF of PROVIDERS (i.e., Anesthesia interventionalists, imaging, dietician, social work, psychology), as appropriate, to maximize positive drug therapy outcomes.