Universal University, and the Marginalization of Pain Education

It’s no secret that “universally”, pain education is marginally covered within healthcare universities including schools of pharmacy, medicine, and nursing.[1]  Three pharmacy students felt so compelled to tell the world how pain education impacted their didactic learning, that they approached me to write a blog.  At first I was hesitant because the content seemed presumptuous for a post on PainDr.com.  But, after much consideration I granted their request, as I believe it tells a very important story to pharmacists, providers, patients, and perhaps most importantly, educators and regulatory agencies.  Perhaps we need to stop the politics and fighting, and admit we have a problem from the word GO.  This has turned out to be the lengthiest blog ever, so I’m hopeful it will keep your attention!

I strongly encourage any and all pain colleagues to comment herein especially if you are lucky enough to have a pain elective or significant coverage within your professional curriculum, regardless if it is pharmacy, medicine, or nursing.

Pharmacy Students Michaela Gardinier, Sonya Vargulick, and Abhishesk Shrivastava had the following to say…

As pain, pain management (or lack thereof) and pain politics (especially surrounding opioid therapy) become more prevalent in America, it is evident that healthcare professionals are under-educated in the field.  In fact, many misinformed clinicians have aligned with mainstream media, resulting in panic and misinterpreted or even propagandized mainstream published reports and talk radio. Completing the didactic class years of pharmacy school, we had negligible exposure to pain or pain therapeutics in our core modules.  Our only option for pain education came in an elective class during our last semester of didactic learning with Dr. Fudin’s Pain Management Pharmacotherapy.  As an elective course at the tail end of our didactic years, not many students had the opportunity or even ambition to take this insightful, jam-packed, informative course which included several pharmacologic drug classes, interactions, practical cases and even legal cases.

While on Advanced Pharmacy Practice Experience (APPE) rotations, we have worked with other pharmacists and students, medical residents, physician assistants, doctors and nurses – all of whom have little to no formal education in pain themselves.  At the same time, we have all witnessed numerous patients suffering from pain, many in whom suboptimal treatment by these healthcare professionals is the norm.  It is evident that the time has come to require mandatory pain education for all healthcare professionals.  That said; it was exciting to see that New York State will likely require at least some education on pain management to healthcare professionals during the collegiate years and following licensure!

Education in pain management is beneficial in so many ways!  It teaches us as professionals how to manage pain and exposes us to some of the most complex and controversial prescription medications.  It provides us with the knowledge and tools to best help our patients suffering from one of the country’s most debilitating conditions.  With the “war on opioids” and the looming “opioid epidemic” preventing patients with legitimate pain from obtaining much needed medications, there needs to be more healthcare professionals with the appropriate skill set to manage, or at the very least to recognize when they are in over their heads in terms of treatment options and need for multidisciplinary intervention(s).

Sonya Vargulick: During my final semester on-campus I debated whether or not to take the Pain Management elective taught at ACPHS. Despite the fact I had already completed all of my elective credits required for graduation, and previous students had informed me the class was a lot of work, I felt the knowledge I had regarding pain management was minimal and any additional information I could learn would be helpful in my future pharmacy career. That decision turned out to be one of the best decisions I made during my attendance in pharmacy school, and I know my patients and I will continue to benefit for years to come. I continually use the knowledge I gained in this class DAILY on my APPE rotations and within the community pharmacy, in which I am employed.

There is one situation in particular that stands out in my mind for which the elective class unwittingly proved beneficial. While working at a rural hospital, I was asked to review a patient’s medical record and make a recommendation regarding a significant adverse event.  Upon review of the chart, I immediately picked-up on a serotonin-like syndrome in a patient receiving high dose tramadol with an SSRI.  Steps were taken to mitigate an already significant adverse cardiac event.  Thankfully, during the pain management elective, tramadol’s mechanism of action had been drilled into my brain, specifically that is a “weak” opioid agonist to the mu-opioid receptors, but also exerts serotonin and norepinephrine reuptake inhibition.  Without this class, I may not have been able to pick up on this interaction so quickly!

Everyone knows someone who suffers from a pain condition, which supports that knowledgeable pharmacists, with the expertise in pain management, should be a priority. I learned more than just the pharmacology of opioids and their side effects. This class helped improve my critical thinking skills, and strongly enhanced my research capabilities. Homework assignments consisted of real patient cases that made us think “out-side the box”. These assignments helped build my confidence and helped me become accustomed to real-life situations; the type of situations for which there is not a correct multiple choice answer.  I learned well that treating patients in real life is not a “multiple choice” decision or guess, and there may or may not be time to ponder over an emergent need for drug(s) selection.

Michaela Gardinier:  Last year I had the privilege of taking the pain management elective.  Never did I imagine I would learn so much in every class!  In our pharmacy education, we have no exposure to pain or pain management.  Prior to deciding on the elective, I met with Dr. Fudin and talked with him about both his elective class and his Ambulatory Care APPE rotation, I was stunned by the clinical involvement that his students were exposed to and even more impressed by his confidence in the students, the expectation of direct patient care activities and collaborative team care involvement with non-pharmacist providers, all of which he encouraged and embraced.  We learn about these things, but active participation is infrequent, at least not to this extent – the possibilities seemed incredible and they were!

First on my agenda was the elective class.  This class was helpful in many ways.  I learned about pain, expanded my psychopharmacology and therapeutics knowledge and was required to back up my answers with convincing references.  This class was the one that I feel most prepared me for rotations.  We were taught to validate our answers with reliable primary references, something seldom required in other classes.  Text sources such as Lexicomp were not permitted.   We really learned to go into each assignment with an open mind and read up on the topic and available research/education sources before answering the question.  We saw poor evidence articles published in some journals and misaligned guidance in various reference books.  If we were called upon in class and didn’t have the adequate information to support our answer, the professor was quick to call us out on it but he also explained why we were led down a primrose path to the less adequate drug choice.   We learned that you have to put the time and effort in to get the most you can out of the work.  No other class rewarded us based on the time and effort to search for what was best for the patient versus answering a series of questions correctly.  You no longer had those students who could look at the material once and get an A on the test.  Instead, you had a group of students who were finally rewarded for their passion, time and effort.

My previous rotation has really opened my eyes to just how important this class really was to my education.  I was on rotation with an inpatient Pain and Palliative Care team.  On a daily basis we saw patients in all different types of pain.  Some patients had pain from cancer, others were post-op (usually total knee replacements), there were chronic non-cancer and acute pain patients as well.  No matter what the pain, the goal is to get the patient’s pain to a tolerable level.  If I had not had the prior exposure to pain management, it would have taken me the first couple weeks on rotation to know where to start.  Lucky for me I already had a therapeutics foundation in pain, so I was able to jump in on the second day and help with recommendations!  This made the rotation more rewarding for me, but also for the team with whom I worked.  I was able to jump in as a knowledgeable part of the team – someone who knew what questions to ask, what information to look for in a patient’s chart, and what changes would best help the patient’s pain.  That rotation bolstered my confidence and made me extremely thankful for my pain education.  I encourage all students who have an option to learn about pain management, to do so.  As Sonya has mentioned above, it will come into play in other practice settings – not just pain specific settings.

While I was on rotation in Dominica (a smaller Caribbean island) I educated people on pain.  Almost every patient at the health stopped by and asked questions about pain, because either they had pain or someone they knew suffered from pain.   It was wonderful to see how grateful they were to have someone answer their questions.

And now, I have since started my Pain Management rotation at the VA in Albany, NY and words cannot express the terror and amazement I felt during the first 10 minutes of the rotation.  As I was getting my mini tour of the hospital, we stumbled upon the primary care pain team.  We did quick introductions and next thing I knew I was skimming a patient’s chart, catching up on what I missed.  Next, we went to go over the plan with patient and I was shaking in my boots when Dr. Fudin turned to me and said “I hope you are getting all this, as you will be writing this note”.  I was so stunned that with appropriate questions, which seemed “second nature” to the team, a plan to better manage the patient’s pain was quickly put in place.  Now, as I approach my final week of the experience, I am still stunned.  This time I am taken aback by my ability to pick up on key factors and determine what course of action might best benefit the patient, which in some cases includes simplifying a drug regimen and in others, rational polypharmacy.  I am sure the repetition from day to day is helpful, but nothing can beat a proper education from an expert in pain management.  I have learned to look at the mechanism of a patient’s pain and the mechanisms of the available medications to guide me in picking the best medication for them.

I am so thankful for the exposure I have received in pain management, and I hope to one day use that knowledge to best serve my patients.

Abhishek Shrivastava: Why is an elective on pain management important? Is it even necessary to offer such an elective to students enrolled in pharmacy school? These are great questions to ask! In an attempt to answer these questions, consider the following situation: You are a clinical pharmacist at an institution and a primary care provider approaches you and asks you to interpret a patient’s serum level of oxycodone that is prescribed at 40mg extended release tablets to be taken twice daily. You are asked to provide a recommended opioid dose after you have assessed the results. In analyzing the patient’s blood work, the serum level of oxycodone came to a whopping 15ng/mL! So what do these results really mean? Any takers? How about a multiple choice…. A. The patient is taking the medication as prescribed as the serum levels correspond with the dose prescribed. B. Fentanyl patch should be considered with a requirement to return to clinic with the used patches. C. These levels are not possible based on the prescribed dose. D. These levels are possible if the patient is an ultra-rapid 2D6 metabolizer – consider pharmacogenetic testing. E. Dose of new opioid should be based on the actual serum level rather than prescribed dose in order to prevent overdose. F. Consider an opioid that undergoes metabolism through a different metabolic pathway. These are just some of the questions a well-trained pharmacist in pain management should be asking.

As a future pharmacist, if I was asked this question before I had completed the pain management elective course, I really would not have any idea where to begin, much less even decipher an adequate recommendation from a journal or book. As someone who had no experience working in community or clinical pharmacy, I didn’t even know what some of the brand names of opioids were, such as MS Contin, let alone assessing serum levels! Perhaps more importantly, most, if not the majority of pharmacy curriculum offer just a single presentation on opioids and the “pharmacology” (2 hours at max).[1] Considering the amount of people who suffer from acute and chronic pain are greater than the amount of people diagnosed with diabetes and hypertension combined, something needs to be done about the current pharmacy and medical curriculum to provide more education on pain management.[1] Consider this statement: Not everybody in the world has diabetes; not everybody in the world has hypertension; however, at some point in an individual’s life, they have felt pain, either physically or mentally. Additionally, since opioids are amongst the most commonly prescribed medications in the United States, one would think that health care providers (especially pharmacists), would receive more than 1-2 hours of lecture in their core curriculum.

In my personal experience, pain management has opened up many doors for my future. Before the elective, I had decided to start looking for jobs in community pharmacy. However, around late February, I got the unfortunate news that my grandfather had been diagnosed with stage IV non-small cell lung cancer. I quickly booked my flight to go see him during spring break; I traveled to India to visit him one last time. During my time there, I could see that he was suffering from pain as the cancer had metastasized to his bones, however, I felt helpless because I did not have the confidence to offer appropriate recommendations. I did not have access to any guidelines as we did not have any access to internet so I was really ashamed of myself. After that point I made it a priority to learn as much as I could in all areas of therapeutics, but most particularly pain management. When I came back to the States, I was more attentive in class, especially the pain management elective, and I chose my rotations going into my P4 year based off what I felt needed improvement. I chose a rotation in pain management. My passion fueled by my grandfather, has helped me to excel at my other rotations.  I never imagined so much would come from one course in pain management.

All in all, I feel it is imperative that health care providers receive more education on pain management, preferably by having institutions hold mandatory pain management courses pre and post graduation. If you ask a pharmacist what the therapeutic level of digoxin should be, without hesitation they will answer “0.5-1 ng/mL” or if you ask a pharmacist what the expected level of lithium is for a 900mg daily dose, sure enough without any hesitation they would reply saying “the PK of lithium is linear therefore the expected level would be approximately 0.9 ng/mL.” However, if you ask a pharmacist what the expected level of oxycodone should be if a patient is prescribed Oxycontin 10mg taken BID, they would have to look it up and find that the expected level should be 15.1 ng/mL + 4.7 ng/mL for that dose.

It’s time that core curriculums include pain management as an essential topic and that various medical clinicians and pharmacists know as much about pain management as they do about algorithmic guidelines in diabetes, hypertension, cholesterol management, common infections, etc.
I learned that although pain is pervasive, learning how to treat it is scarce.  I was one of the lucky ones!

JF: Readers, please tell us about pain education at your institution!

1. Herndon CM, Strassels SA, Strickland JM, et al. Consensus recommendations from the strategic planning.summit for pain and palliative care pharmacy practice. J Pain Symptom Manage. 2012;43:925-944.

Michaela Gardinier is a Pharm.D. Candidate, 2014   at Albany College of Pharmacy and Health Sciences.  Over the past two years, she has taken a   special interest in the practice of pain management and is now on a learning rotation with Dr. Fudin.

Sonya Vargulick is a   Doctor of Pharmacy Candidate, 2014 at Albany College of Pharmacy and Health   Sciences.  Throughout college Ms.   Vargulick was active in Colleges Against Cancer and volunteered at a local   clinic to provide healthcare to the underprivileged members of the community.   This past summer, Ms. Vargulick had the opportunity to complete a pharmacy   rotation at Fudan University Shanghai Cancer Center, Shanghai, China, where   she gained an appreciation for Traditional Chinese Medicine. She is currently   on a learning rotation at an independent community pharmacy in Watertown, NY.

Abhishek Shrivastava is a Doctor   of Pharmacy Candidate, 2014 at Albany College of Pharmacy and Health   Sciences. Hobbies include weight training, basketball, and reading. Aspiring to   be a clinical pharmacy specialist in pain management.