Experts discuss complex issues related to hospital pain management

Troubleshooting is big part of job

Hospitals that have pain management teams with pharmacists on board benefit from having a medication specialist help improve safety and improve patient outcomes, experts say.

It's a complex issue, says David Craig, PharmD, BCPS, clinical pharmacy specialist and residency director in psychosocial, palliative care, and integrative medicine at Moffitt Cancer Center in Tampa, FL.

"How do you control and provide safety for patients with these medicines that can cause harm?" Craig says. "But on the other hand, how do you better manage patients with all types of pain?"

A start would be to hire a pharmacist pain specialist or at least include a pharmacist on a pain management team, says Lee Kral, PharmD, BCPS, a clinical pharmacy specialist in pain medicine at the University of Iowa Hospitals and Clinics in Iowa City, IA.

"A lot of hospitals don't have the resources to have someone do pain management full-time," Kral notes. "We're often called upon as pharmacy team members to come up with unique ways to treat pain."

Kral became interested in pain management after practicing in primary care and neurology.

"Most of my day is seeing chronic, noncancer pain patients in the clinic setting, and I also work with the palliative care team at the hospital," Kral says. "We see some cancer patients and some post-operation patients."

"My job here is 80% troubleshooting," Kral says.

For example, Kral had a patient a couple of years ago who had been prescribed a medication that was contraindicated in patients with liver insufficiency.

"I looked at this patient and saw that the person had hepatitis and was having some liver insufficiency," Kral recalls.

So she helped get the patient's prescription changed.

"If pharmacists are consulted for pain management in a patient with congestive heart failure, then we'd be reluctant to prescribe an anti-inflammatory because it might cause fluid build-up," Kral says.

In another case, a woman with gynecological cancer and who had a toddler was unable to tolerate high doses of opioids because it left her sedated and constipated, Kral recalls.

"We wanted to make her comfortable and mobile with a better quality of life," Kral says. "So we utilized an intrathecal pump to deliver pain medication to the central nervous system to control her pain."

By sending opioids directly to her cerebrospinal fluid, the treatment dose was effective at a considerably smaller dose, and it did not impact the woman's ability to think, Kral says.

"Her bowel function got better, her pain improved, and she was doing great," she adds.

These are only a few examples of how a pharmacist can help improve safety.

But pharmacists also can help patients achieve better pain control by coming up with pharmaceutical solutions, Kral says.

"We had a patient referred to us for refractory hemorrhoidal pain," Kral says. "We couldn't give the patient opioids because that would cause constipation and make passage more difficult and painful, making the hemorrhoids worse."

So when the patient was referred to the pain management team, Kral suggested that they try using a topical medication.

"Opioid receptors are expressed in areas of inflammation, so we could use a topical treatment and add morphine to that to see if we could utilize those opioid receptors that are expressed in the hemorrhoidal inflammatory area," Kral says. "So I called up a compounding pharmacy that's outside the hospital, and the pharmacy made a formulation."

The patient used the topical treatment, and when he returned for a visit six weeks later he reported no pain, Kral adds.

Hospital pharmacists also can assist with the complex psychosocial and regulatory issues related to pain management.

"We need to have more clues and more information about patients and their disease states to do a better job of pain control," Craig says. "Both patients with chronic pain from cancer and noncancer need better pain control."

The challenge is helping patients with severe, noncancer pain achieve optimal pain control within regulatory boundaries, he notes.

Regulations limit the dosage patients can receive, although there are some exceptions for patients with cancer pain, Craig adds.

"Everyone's greatest concerns are diversion and abuse," Kral says.

"The medication isn't available to patients usually, and the drugs are locked up with a controlled substances monitoring sheet," Kral says. "So that aspect [of potential abuse] doesn't concern us as much as having a patient bring in a substance to the hospital or having a family member or friend bring it in."

The patient might have been abusing pain medications at home and is doctoring his hospital regimen with the home-based products, she adds.

Or another problem is staff diversion, Kral says.

"That's a bigger issue," she notes.

Although the security procedures work well, there is an opportunity in a night shift for a hospital employee to sign out a pain medication for a patient and then not give it to the patient, although it's documented that the patient received it, Kral explains.

"That kind of problem is hard to track down," she adds.

Another reason why pain management is so complex is because of the psychosocial aspect to pain.

"Pain is very subjective," Kral says. "Multiple factors go into how a patient perceives pain, and sometimes there isn't any medication that's going to relieve their pain if the pain is contributed to by a concurrent depression or by social stressors."

This is why pain teams need a pain psychologist who will help patients with chronic pain cope with it and deal with it.

Also, pharmacy pain specialists need to develop skills for dealing with patients' psychosocial issues.

"I tell patients, and they're not very happy when I tell them this, but my personal professional recipe for pain management is 10% interventional, 10% medication, 20% rehabilitative, 20% cognitive therapy, and 40% the patient's motivation and drive," Kral says.

Patients with chronic pain often want a magic pill that will make all of their problems go away, Kral says.

"So it's important to be realistic and pragmatic up front, telling them that we'd like to try this combination of medications for these reasons," Kral explains.

A pharmacist specializing in pain management could educate patients about how the medication will do its part, but the patient also will need to continue improving with his rehabilitation and develop realistic expectations, she says.

"They have to be invested in their own recovery, and many times it's up to me to very gently and supportively say that I don't think whatever medication we give them will be a magic pill, but we're optimistic it will blunt the pain," Kral adds.

"We may not be able to get rid of the pain 100%, but we can help patients get back to a level of functioning that allows them to have their life back," Kral says. "So they can do their jobs and be an active member of their family and friendship circle."