Physicians Dread it; Pharmacists Dream of it. Tackling the Opioid Epidemic & Analgesic Toxicity by Collaborating

Share with others

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 hereIt 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. 

Left to Right: Jeffrey Fudin, PharmD; Abhinetri Pandula, MD; Annette Payne, PhD; Timothy Atkinson, PharmD. It takes a neighborhood!
Left to Right: Jeffrey Fudin, PharmD; Abhinetri Pandula, MD; Annette Payne, PhD; Timothy Atkinson, PharmD. It takes a neighborhood!

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:

  1. Comprehensive analgesic pain medication evaluation including all medication therapies but with a focus on analgesic therapies and potential drug interactions.
  2. Medication history review and reconciliation
  3. Initiation, modify and/or recommend medication regimens as allowable by current regulation
  4. Assessment of adherence to medications
  5. Risk assessments evaluations and documentation with validated tools and lab analysis
  6. SOAP-R
  7. COMM
  8. Urine Drug Test evaluations
  9. Immune Assay
  10. Qualitative Testing (gas or liquid chromatography mass spectrometry (GC-LCMS)
  11. Adulteration Behavior Checks (ABC) and Specimen Validity Testing (SVT)
  12. Behavior modification techniques and follow-up services for nonadherence
  13. Pharmacokinetic and clinical monitoring of medications
  14. Pharmacogenetic testing and interpretation of results
  15. Patient education regarding self-administration and monitoring of medications
  16. Monitoring for therapeutic effects, drug interactions, and adverse drug events through drug regimen review, laboratory data/vital sign assessment and patient interview
  17. Identification of and monitoring for behaviors of medication misuse, abuse, and/or addiction
  18. Assist with the development of clinical protocols to encourage the systematic approach to and use of various analgesic therapies
  19. Provide educational conferences to staff and affiliates on topics related to pain pharmacotherapy
  20. Conduct academic-detailing and/or drug use evaluations and respective outcomes
  21. Assist with quality improvement projects to improve processes related to patient care

Competency for position includes

  1. Chronic pain syndromes
  2. Pain pharmacotherapy
  3. Knowledge of interventional therapies
  4. Risk assessment and management
  5. Toxicology and urine drug screening evaluation
  6. Responsible opioid prescribing/universal precautions
  7. Behavioral interventions
  8. Motivational interviewing
  9. Addiction medicine
  10. Inter-professional communication and collaboration
  11. Referrals when appropriate
  12. Prescribe medications

CLINICAL PHARMACIST IN PAIN MANAGEMENT, GENERAL FUNCTIONS AND SCOPE OF PRACTICE

  1. Conduct comprehensive appraisals of patients’ health status by taking health and drug histories. Relevant findings must be documented in the patient’s medical record.
  2. 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).
  3. Develop and document therapeutic plans utilizing the most effective, least toxic, and most economical medication treatments.
  4. Provide patient and health care professional education.
  5. Order, perform, review, and analyze appropriate laboratory tests and other diagnostic studies necessary to monitor and support the patient’s drug therapy.
  6. Perform the physical measurements necessary to ensure the patients appropriate clinical responses to drug therapy.
  7. Assist in the management of medical emergencies, adverse drug reactions, and acute and chronic disease states.
  8. Identify and take specific corrective action for drug-induced problems.
  9. Order consults ON BEHALF of PROVIDERS (i.e., Anesthesia interventionalists, imaging, dietician, social work, psychology), as appropriate, to maximize positive drug therapy outcomes.

10 thoughts on “Physicians Dread it; Pharmacists Dream of it. Tackling the Opioid Epidemic & Analgesic Toxicity by Collaborating

  1. THis article was very insightful. I am amazed there is no accurate care for chronic pain patients. Suicide rates will go up. Maybe this should be a statistic to keep track of. Patients taken off proper medications, Opioids, that commit suicide shortly there after. Proper medications are a necessity. Never give up. It takes caring Drs. and patients that are able to fight for their rights.
    signed,
    Fearful in San Diego

  2. Dear Dr Fudin:
    Great ideas.
    I hope they are implemented.
    In my town CVS refuses to fill my Rx (3stores)
    I suspect they are planning a minute clinic.
    Walgreens argues with every Rx, and claims to
    My patients they should be seeing someone else got the same Rx.

    Osco fills intermittently.
    And
    Doctors abandon patients regularly. When I see the patients and write their Rx, suddenly I am some criminal with the board of medicine and DEA threatened by my care of patients in pain, most of whom wean.

    The practical world of pain treatment is a world of discrimination
    Suspicion
    So called red flags
    AND NO EVIDENCE.
    And
    No law enforcement agencies actually doing their job : find the bad guys, keep it safe for the good guys.
    We don’t criminalize car dealers for selling vehicles to people who might speed. Why scare doctors for prescribing to pTients who might divert.
    Since there are an estimated 6 million addicts
    And 100 million pain patients
    Treating patients like addicts is 94% likely to be WRONG.

  3. Dr. Fudin

    Your insight is always valuable to those of us in the pain management field. I am a PGY2 Pain trained pharmacist working in the VA system. I chose to work in the VA because of the collaborative nature established with pharmacist so that I could utilize the skills developed through training. I work within an interdisciplinary pain management team and have some prescriptiive authority for medication management (there are actually 2 pain management pharmacist on our team, and I think I 3rd could be utilized in the future). Primary care providers find the clinical pharmacy pain management services very valuable as attested to by approx 140 consults to our service every month. Patients also value our sevices because we can take time to listen and collaborate with the patient on their pain management goals, we educate, advocate and support patients on their pain management journey. Patients often tell our administration how valuable all of the clinical pharmacist are in their health management.

    1. Christina,
      Thank you for posting this supportive narrative. After your training at the North Florida South Georgia Veteran’s Health Administration, I’m sure you’ve seen a lot of clinical issues that prepared you well for your current role at the Southern Arizona Veteran’s Health Administration. Hopefully you work with my good friend and colleague, Dr. Linda Tristani. I’ll be watching to see that you eventually start up a PGY2 training program there – AZ can use one!

  4. So, along with the pain specialist, rheumatologist, neurologist, acupuncturist, cancer specialist, physical therapist, chiropractor, massage therapist, nutritionist, hypnotist, biofeedback specialist, gynecologist, PCP, and therapist, a pain patient will also need to pay for a clinical pharmacist? Is this for the benefit of the DEA, insurance companies, doctors, or the ACA? (You’ll notice I didn’t include patients in that list.)

    And since the under-treatment of pain is only increasing, shouldn’t one of the specialists on a pain patient’s team be an expert in suicide prevention? Sure, you could say that all this patient monitoring will allow doctors to see symptoms of suicidal ideation when it emerges, and yet one has to be looking for it to find it. And I don’t see the term “suicide” anywhere in the job description of a clinical pharmacist.

    Pain patients already have to pay to be monitored for addiction, and now they are also considered to be potentially at risk for suicide — add a psychiatrist to the team. (Are all psychiatrists required to have training on suicide prevention? No, I don’t think they are.)

    Will adding monetary barriers for patients make the problems any better? Yes, a pain patient deserves a group of doctors all working on the same goal, but who can afford that? And I don’t think it’s fair that only patients who can afford all this monitoring will have access to pain medications. The system has been like that for years, and it’s just plain cruel… patients on Medicaid tragically dying from being spoon-fed risky drugs like methadone for pain.

    Maybe what’s needed is a whole new government agency just for pain patients, right? An agency that answers to the NSA, because this agency is an expert at monitoring people. An agency responsible for monitoring and keeping track of 28 million (or 100 million) pain patients. Should I get my forearm stamped with a bar code?

    And now I’m wondering… Will clinical pharmacists have a duty to report mistakes made by pain patients to the DEA? Because all of this monitoring has consequences, and most of them criminal. In case the medical industry was unaware, drug addiction is a crime in this country. And when the medical industry is in league with the DEA (and insurance companies), how are patients supposed to trust them?

    1. Johnna,
      You have it all wrong. A patient should not need to see a clinical pharmacist IN ADDITION TO or ADDITIONALLY PAY FOR a clinical pharmacist. The patient would see the clinical pharmacist instead of a medical doctor or NP or PA for specific attention to their medication needs. The medical doctor could then focus on medical and diagnostic needs. And, this is not about PAIN patients only; it’s about all patients in several medical settings. It would be more cost effective and most probably would prevent medication errors and reduce hospital admissions across all domains, not just pain management.

      To clarify, I pasted the role of a general clinical pharmacist below from the American College of Clinical Pharmacy website located at this LINK. Standards of practice for a clinical pharmacist as outlined by ACCP is located at this LINK.

      What is a clinical pharmacist?
      Clinical pharmacists work directly with physicians, other health professionals, and patients to ensure that the medications prescribed for patients contribute to the best possible health outcomes. Clinical pharmacists practice in health care settings where they have frequent and regular interactions with physicians and other health professionals, contributing to better coordination of care.

      The clinical pharmacist is educated and trained in direct patient care environments, including medical centers, clinics, and a variety of other health care settings. Clinical pharmacists are frequently granted patient care privileges by collaborating physicians and/or health systems that allow them to perform a full range of medication decision-making functions as part of the patient’s health care team. These privileges are granted on the basis of the clinical pharmacist’s demonstrated knowledge of medication therapy and record of clinical experience. This specialized knowledge and clinical experience is usually gained through residency training and specialist board certification.

      What do clinical pharmacists do?
      Clinical pharmacists:

      Assess the status of the patient’s health problems and determine whether the prescribed medications are optimally meeting the patient’s needs and goals of care.
      Evaluate the appropriateness and effectiveness of the patient’s medications.
      Recognize untreated health problems that could be improved or resolved with appropriate medication therapy.
      Follow the patient’s progress to determine the effects of the patient’s medications on his or her health.
      Consult with the patient’s physicians and other health care providers in selecting the medication therapy that best meets the patient’s needs and contributes effectively to the overall therapy goals.
      Advise the patient on how to best take his or her medications.
      Support the health care team’s efforts to educate the patient on other important steps to improve or maintain health, such as exercise, diet, and preventive steps like immunization.
      Refer the patient to his or her physician or other health professionals to address specific health, wellness, or social services concerns as they arise.
      How do clinical pharmacists care for patients?
      Clinical pharmacists:

      Provide a consistent process of patient care that ensures the appropriateness, effectiveness, and safety of the patient’s medication use.
      Consult with the patient’s physician(s) and other health care provider(s) to develop and implement a medication plan that can meet the overall goals of patient care established by the health care team.
      Apply specialized knowledge of the scientific and clinical use of medications, including medication action, dosing, adverse effects, and drug interactions, in performing their patient care activities in collaboration with other members of the health care team.
      Call on their clinical experience to solve health problems through the rational use of medications.
      Rely on their professional relationships with patients to tailor their advice to best meet individual patient needs and desires.
      How do you find a clinical pharmacist?
      Clinical pharmacists practice in many different health care environments: hospitals and their affiliated outpatient clinics, emergency departments, community pharmacies, physicians’ offices, community-based clinics, nursing homes, and managed care organizations.

    2. Johnna does NOT have it wrong. We are so way off course now with this newest blog. What a disappointment to read this. A pain specialists brain should be large enough to retain what is needed. Listen to the patient and treat.

      1. I will try this one Jeff.

        The problem, as a pain physician trying to tackle all of the issues highlighted by Dr Fudin eclipse all the best efforts of any one individual physician. Period. I have almost 25 years of post residency training with the best in the world. I regularly attend and am asked to present at local, national and international meetings as an expert. I have empathy and concern for my patients, seeing over 100 patients every week.

        I need all the help I can get! And I help write the articles, do the lectures and serve as a national resource. But Dr. Fudin knows more than I will ever know. His colleague at Albany, Charles Argoff, MD knows more neurology than I will ever know. Similarly Steve Passik and Jeff Gudin know more about there respective fields than I will ever know.

        A physician who does not recognize his or her limitations and remains a single trick pony will do limited and possibly harmful treatments if they do not work in a collaborative.

        Sorry Jeff, I could not help myself.

        Mike Brennan

        1. Sorry Mike? WOW! I’m humbled by your words and am proud to even be mentioned on the same page and considerd a collaborative colleague to you, Drs. Argoff, Passik, and Gudin. It does take a neighborhood and I respect all that each and every one of you has done for the medical profession, pain management, and collaborative patient care. The four of you rank high on my list of heroes!

  5. Dr. Fudin,

    It makes perfect sense that prescribers should collaborate with pharmacists. Whose brain is large enough to retain all of the clinical information out there? Not mine, that’s certain. I have always valued a close working relationship with my pharmacist colleagues, so much so that I included it in my first ever “Top Ten” list on how best to safely prescribe controlled substances for chronic pain. Most of the list is still very true, especially number nine:

    (9) “Get to know the pharmacists.”

    If anyone would like to know the rest of the story, the entire list is available to view here (from Louisville Medicine, March 2004):

    http://jamespmurphymd.com/2014/11/21/treating-pain-patients-like-addicts/comment-page-1/#comment-1186

Leave a Reply to Christina Creech Cancel reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.