Pharmacist s Role In Pain Management. Katrina Lynn, Pharm D PSHP Annual Assembly: October 12, 2017

Transcription

1 Pharmacist s Role In Pain Management Katrina Lynn, Pharm D PSHP Annual Assembly: October 12,

2 Presentation Objectives Briefly discuss Geisinger Health System and the use of Pain Management Pharmacists in patient care Analyze statistics of the opiate epidemic Describe important aspects of implementing a pain program Discuss beneficial outcomes Geisinger has seen since starting its own Pain MTM clinics 2

3 Pharmacists can play an important role in chronic pain management 3

4 Pain free is an appropriate goal for chronic pain management patients 4

5 The best way to treat chronic pain is with medications alone 5

6 Geisinger Health System 6

7 MTDM Program Timeline Chronic Obstructive Pulmonary Disease Anticoagulation Metabolic Disorders Hematology/Oncology Heart Failure Anemia Insulin Pumps Intracranial stents Rheumatology Crohn s Disease Ulcerative Colitis Anemia Chronic Kidney Disease Chronic Noncancer Pain Medically Complex Children Multiple Sclerosis Psoriasis Hepatitis C Asthma Neuroimmune modulators Familial Hypercholesterolemia 7

8 Program Goals Patient Safety Identify and treat high-risk population Decrease emergency room visits and hospitalizations for pain/overdose Mitigate risk for opioid abuse/diversion Reduce risk of intentional or accidental overdose Patient Focused Care Educate patient Work with patient to establish realistic goals and exit strategy Enhance patient functionality Improve overall quality of care and patient satisfaction Treatment Optimization Minimize use of chronic high dose opioids Actively incorporate opioid sparing adjuvant medications Collaborate and utilize available interdisciplinary and community resources Decrease overall cost of care 8

9 Physician Feelings on Opioids 25% of physicians feel confident managing the opioids they prescribe 60% of physicians state time limitations in the exam room inhibit opioid prescribing from being a priority 9

10 Opiate Prescriptions Dispensed in U.S. 10

11 Opiate Consumption in U.S. 11

12 Nonmedical use of Prescription Pain Meds ML2013/Web/NSDUHresults2013.htm 12

13 NIH. Overdose Death Rates. Revised December

14 Powerful Medications In ,329 people died of a drug overdose in the US 22,134 involved pharmaceutical drugs 16,651 deaths were due to prescription opioids Prescription Drug Overdose 75% of deaths are from opioids (3 of every 4 deaths) "Drug Overdose Deaths up for 11th Year." United Press International. N.p., 20 Feb Web. 28 July

15 Breaking Down the Numbers 16,651 deaths x 825 = 13,737,075 people abusing prescription opioids That is equal to the entire population of PA, Washington DC, and half of Vermont (2013 data from census.gov) 15

16 What does a High Risk patient look like?! 16

17 PA Annual Drug-Induced Death Rate: 2005 Nmalaw Nick Malaw skey. "Mapping Pennsylvania's Worsening Heroin Crisis." PennLive.com. PennLive.com, 02 Mar Web. 28 July

18 PA Annual Drug-induced Death Rate: 2013 Nmalaw Nick Malaw skey. "Mapping Pennsylvania's Worsening Heroin Crisis." PennLive.com. PennLive.com, 02 Mar Web. 28 July

19 A multidisciplinary approach is essential for optimal pain control Because pain affects all aspects of your life, medications alone are not the answer. We need to address the physical, emotional, social and spiritual aspects of your pain as well. Physical Spiritual Social Emotional 19

20 Setting Expectations Complete pain relief is not reasonable, nor is expecting to be able to return to the same degree of activity that the patient had previously. Treatment is not just about pain relief, it s also about improving the patient s ability to do more on their own. 20

21 Setting Expectations Realistic and Shared Goals: Decrease pain (intensity, frequency) Decrease suffering Enhance self control Improve function Improve sleep Improve mood/decrease distress Increase activity (work, recreation, etc) 21

22 Expectations of Patients Signing a Medication Use Agreement (MUA) with physician Urine Toxicology Screens are expected at least once to twice per year and are random Pill counts at every visit 22

23 The Four A s of Opioids Analgesia Does the patient have effective pain relief? Adverse effects Are they severe, limiting, or are they controlled? Activity Evidence of increased function with opioids? meeting activity goals? Aberrant Behavior Screen/monitor Not getting the right answer on 4As? Then STOP! 23

24 Discontinuing Opioids Patients who exhibit instances of medication aberrant behavior (e.g., broken Med Use Agreement) Patient preference No improvement of function or developing tolerance despite 2-3 dosage increases Experiencing intolerable adverse effects E.g., excessive fatigue, sedation, falls, CNS toxicity, opioidinduced hyperalgesia 24

25 How to Taper Opioid Therapy Keep the instructions uncomplicated Weekly, bi-weekly, or monthly intervals Written instructions Slow taper if possible 10% reduction at a time (10-25% acceptable) One size does NOT fit all for opioid tapering Some patients taking high doses (> 200mg MED) may tolerate more rapid tapers at first Close follow-up and withdrawal symptom control are important 25

26 Opioids + Benzodiazepines AVOID! Opioid overdoses usually have polysubstance involvement Risk of overdosage increases with benzodiazepines Benzodiazepines have high physical dependency potential 26

27 Plan Managing chronic pain requires a comprehensive approach that might include: Physical therapy Cognitive behavioral therapy Titrating medication regimen Exercise programs The goal is to optimize pain relief, improve outcomes, and reduce dependence on opioids. 27

28 MTDM Pain Management: Outcomes Internal retrospective analysis of the Geisinger MTDM Pain program for patients with chronic, non cancer pain compared: Patients managed by MTDM Pain pharmacists, practicing under the guidance of a pain physician Non-pharmacist-guided patients not enrolled in MTDM Pain Program Included: Patients on high doses of Morphine Equivalents per day Patients on short acting and long acting opioids Patients on Methadone 28

29 MTDM Pain Management: Outcomes 2014 GHS Pharmacy Resident project results showed 52% decrease in Morphine Equivalent per day (MEQ/D) with control group showing a 16% INCREASE in MEQ/D for GHS patients over the past 18 months. 29

30 Pain Pharmacists Reduce Amount of Opioids * *Dose is in Morphine Milligram Equivalents (MME) per day 30

31 Pain Pharmacists Reduce Emergency Visits 31

32 Secondary Outcomes: Med Use Agreements 32

33 Chronic Pain-National Level Condition US Patient Population Annual Cost of Care Chronic/Persistent Pain million $560-$635 billion Diabetes 25.8 million $245 billion Coronary Artery Disease 16.3 million $108.9 billion Stroke 7 million $53.9 billion Cancer 13 million $124.6 billion 1. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Institute of Medicine Report

34 Pain Cycle: Living with Pain can be Difficult Eating Habits Sleep Pain and Anxiety make it hard to sleep. Lack of sleep makes pain worse and decreases energy Relationships Energy Coping with pain drains energy. Lack of energy makes it hard to be active and stay in shape Pain Mood Chronic pain and the limits it puts on your life can lead to depression, anger, and anxiety. These feelings make coping with pain harder Finances Activity Pain and lack of energy make it hard to be active. Lack of exercise worsens pain. Normal Activities 34

35 Questions? Recognition: Eric Wright, PharmD, MPH Leeann K. Webster, RPh, CACP CDE Laney Jones, PharmD, MPH Jessica Andersen, PharmD 35