Achieving Optimal Therapeutic Outcomes in Pain Management from a Pharmacist's Perspective

Transcription

1 Achieving Optimal Therapeutic Outcomes in Pain Management from a Pharmacist s Perspective Chris Herndon, PharmD, BCPS, CPE Assistant Professor Southern Illinois University Edwardsville Clinical Pharmacy Specialist St. Elizabeth s Hospital Belleville, Illinois Objectives Distinguish the role of the pharmacist as an important component of the multidisciplinary team in the management of chronic pain Define the concepts of preventive and multimodal analgesia in pain management The Multidisciplinary Team Physician Nurse case manager Mid-level providers Advanced practice nurse Certified registered nurse of anesthesia Physicians assistant Pharmacist Social worker/psychologist/counselor MediCom Worldwide, Inc. 1

2 Evidence of Effectiveness and Mechanisms of Change Decreased pain severity Decreased pain catastrophizing Decreased severity of depression Decreased resource utilization Ref 1-3 Why Pharmacists on the Team Appreciate the Importance of a Multidisciplinary Approach Reduction in average pain intensity Reduction in medication adverse effects Decreased average opioid consumption Increased treatment satisfaction Ref 4, 5 Patients Want Pharmacists Involved in Pain Care MediCom Worldwide, Inc. 2

3 70% Patients Want Pharmacists Involved in Pain Care 60% 50% 40% 30% 20% Currently Discuss with Pharmacist Do Not Currently Discuss But Would Like To Overall Would Like to Discuss 10% 0% Ref 6 Pain Severity Level of Functioning Therapy Goals Side Effects Adherence Would Like Pharmacist to Communicate with Physician 70% Patients Want Pharmacists Involved in Pain Care 60% 50% 40% 30% 20% Currently Discuss with Pharmacist Do Not Currently Discuss But Would Like To Overall Would Like to Discuss 10% 0% Ref 6 Pain Severity Level of Functioning Therapy Goals Side Effects Adherence Would Like Pharmacist to Communicate with Physician 70% Patients Want Pharmacists Involved in Pain Care 60% 50% 40% 30% 20% Currently Discuss with Pharmacist Do Not Currently Discuss But Would Like To Overall Would Like to Discuss 10% 0% Ref 6 Pain Severity Level of Functioning Therapy Goals Side Effects Adherence Would Like Pharmacist to Communicate with Physician MediCom Worldwide, Inc. 3

4 70% Patients Want Pharmacists Involved in Pain Care 60% 50% 40% 30% 20% Currently Discuss with Pharmacist Do Not Currently Discuss But Would Like To Overall Would Like to Discuss 10% 0% Ref 6 Pain Severity Level of Functioning Therapy Goals Side Effects Adherence Would Like Pharmacist to Communicate with Physician 70% Patients Want Pharmacists Involved in Pain Care 60% 50% 40% 30% 20% Currently Discuss with Pharmacist Do Not Currently Discuss But Would Like To Overall Would Like to Discuss 10% 0% Ref 6 Pain Severity Level of Functioning Therapy Goals Side Effects Adherence Would Like Pharmacist to Communicate with Physician 70% Patients Want Pharmacists Involved in Pain Care 60% 50% 40% 30% 20% Currently Discuss with Pharmacist Do Not Currently Discuss But Would Like To Overall Would Like to Discuss 10% 0% Ref 6 Pain Severity Level of Functioning Therapy Goals Side Effects Adherence Would Like Pharmacist to Communicate with Physician MediCom Worldwide, Inc. 4

5 Integration into a Team Community Prospective communication with provider office Review above and beyond aberrant behaviors Opportunities for medication therapy management (MTM) and/or group education Hospice interdisciplinary rounds/care planning Integration into a Team Inpatient/institutional Drug use evaluation (DUE)/medication use evaluation (MUE) Rounding when available Development of an inpatient team or committee Curbside consults Integration into a Team Ambulatory care/outpatient Stand-alone appointments Prospective and retrospective chart review Patient education Curbside consults MediCom Worldwide, Inc. 5

6 Multimodal Therapy Multimodal Therapy Pharmacotherapy Physical Medicine and Rehabilitation Assistive devices, electrotherapy Complementary and Alternative Medicine Massage, supplements Opioids, nonopioids, adjuvant analgesics Multimodal Therapeutic Strategies for Pain and Associated Disability Lifestyle Change Exercise, weight loss Interventional Approaches Injections, neurostimulation Psychological Support Psychotherapy, group support Ref 7, 8 Multimodal Therapy Pharmacotherapy Physical Medicine and Rehabilitation Assistive devices, electrotherapy Complementary and Alternative Medicine Massage, supplements Opioids, nonopioids, adjuvant analgesics Multimodal Therapeutic Strategies for Pain and Associated Disability Lifestyle Change Exercise, weight loss Interventional Approaches Injections, neurostimulation Psychological Support Psychotherapy, group support Ref 7, 8 MediCom Worldwide, Inc. 6

7 Multimodal Therapy Pharmacotherapy Physical Medicine and Rehabilitation Assistive devices, electrotherapy Complementary and Alternative Medicine Massage, supplements Opioids, nonopioids, adjuvant analgesics Multimodal Therapeutic Strategies for Pain and Associated Disability Lifestyle Change Exercise, weight loss Interventional Approaches Injections, neurostimulation Psychological Support Psychotherapy, group support Ref 7, 8 Multimodal Therapy Pharmacotherapy Physical Medicine and Rehabilitation Assistive devices, electrotherapy Complementary and Alternative Medicine Massage, supplements Opioids, nonopioids, adjuvant analgesics Multimodal Therapeutic Strategies for Pain and Associated Disability Lifestyle Change Exercise, weight loss Interventional Approaches Injections, neurostimulation Psychological Support Psychotherapy, group support Ref 7, 8 Multimodal Therapy Pharmacotherapy Physical Medicine and Rehabilitation Assistive devices, electrotherapy Complementary and Alternative Medicine Massage, supplements Opioids, nonopioids, adjuvant analgesics Multimodal Therapeutic Strategies for Pain and Associated Disability Lifestyle Change Exercise, weight loss Interventional Approaches Injections, neurostimulation Psychological Support Psychotherapy, group support Ref 7, 8 MediCom Worldwide, Inc. 7

8 General Treatment Considerations Patient status Nonpharmacologic Pharmacologic Risk management Ethical, legal, regulatory Ref 9 Multimodal Analgesia the use of more than one modality of pain control to obtain additive or synergistic beneficial analgesic effects May include: Combinations of classes of drugs Nonpharmacologic therapies Sequential administration (ie, nerve block) Ref 10, 11 Why Multimodal Analgesia? Improved pain severity scores Improved ambulation postoperatively Decreased residual chronic pain Decreased dose-related side effects Decreased opioid burden Ref 11, 12 MediCom Worldwide, Inc. 8

9 Multimodal Treatment Considerations Patient compliance Analgesia effectiveness Adverse effects Stress Severity of pain Environment Aberrant drug-taking behaviors.ref 13 Types of Aberrant Drug-taking Behaviors Probably more predictive Selling prescription drugs Prescription forgery Stealing or borrowing another patient s drugs Injecting oral formulation Obtaining prescription drugs from non-medical sources Concurrent abuse of related illicit drugs Multiple unsanctioned dose escalations Recurrent prescription losses Probably less predictive Aggressive complaining about need for higher doses Drug hoarding during periods of reduced symptoms Requesting specific drugs Acquisition of similar drugs from other medical sources Unsanctioned dose escalation 1 2 times Unapproved use of the drug to treat another symptom Reporting psychic effects not intended by the clinician Ref 14,15 Types of Aberrant Drug-taking Behaviors Probably more predictive Selling prescription drugs Prescription forgery Stealing or borrowing another patient s drugs Injecting oral formulation Obtaining prescription drugs from non-medical sources Concurrent abuse of related illicit drugs Multiple unsanctioned dose escalations Recurrent prescription losses Probably less predictive Aggressive complaining about need for higher doses Drug hoarding during periods of reduced symptoms Requesting specific drugs Acquisition of similar drugs from other medical sources Unsanctioned dose escalation 1 2 times Unapproved use of the drug to treat another symptom Reporting psychic effects not intended by the clinician Ref 14,15 MediCom Worldwide, Inc. 9

10 Types of Aberrant Drug-taking Behaviors Probably more predictive Selling prescription drugs Prescription forgery Stealing or borrowing another patient s drugs Injecting oral formulation Obtaining prescription drugs from non-medical sources Concurrent abuse of related illicit drugs Multiple unsanctioned dose escalations Recurrent prescription losses Probably less predictive Aggressive complaining about need for higher doses Drug hoarding during periods of reduced symptoms Requesting specific drugs Acquisition of similar drugs from other medical sources Unsanctioned dose escalation 1 2 times Unapproved use of the drug to treat another symptom Reporting psychic effects not intended by the clinician Ref 14,15 Multimodal Drug Therapy Multiple mechanisms of action Methadone Tramadol Tapentadol Levorphanol Multimodal Drug Therapy Multi-drug regimens synergistic Gabapentin/pregabalin Nonsteroidal anti-inflammatory drugs (NSAIDs)/acetaminophen Cannabinoids Ketamine Amantadine MediCom Worldwide, Inc. 10

11 Multimodal Drug Therapy Multi-drug regimens sequential Gabapentin/pregabalin/venlafaxine Nerve blocks/regional blocks Wound infiltration Multimodal Drug Therapy Ref 14 Multimodal Drug Therapy Peripheral Sensitization Topical local anesthetics, opioids, capsaicin, and tricyclic antidepressants Non-steroidal antiinflammatory drugs Ref 14 MediCom Worldwide, Inc. 11

12 Multimodal Drug Therapy Central Sensitization Neuraxial local anesthetics Alpha-2 agonists (eg, clonidine) NMDA-receptor antagonists (eg, methadone) Anticonvulsants (eg, gabapentin, pregabalin, topiramate) Antidepressants (eg, tricyclic and SNRI) Tapentadol and tramadol Opioids Acetaminophen Ref 14 Multimodal Drug Therapy Descending Modulation Opioids Antidepressants (eg, tricyclic and serotonin norepinephrine reuptake inhibitor [SNRI]) Alpha-2 agonists (eg, clonidine) Tapentadol and tramadol Ref 14 Multiple Mechanisms of Action in Pain MediCom Worldwide, Inc. 12

13 Multiple Mechanisms of Action in Pain Proposed mechanism of action in pain Drug Opioid NE 5HT NMDA K NaV Tapentadol Tramadol Amitriptyline ? Levorphanol Methadone Milnacipran Venlafaxine Ketamine Opioid = mu, kappa, or delta activity; NE = norepinephrine reuptake inhibition; 5HT = serotonin reuptake inhibition; NMDA = N-methyl-d-aspartate glutamate antagonism; K = voltage gated potassium channel upregulation; NaV = voltage gate sodium channel blockade Ref Multiple Mechanisms of Action in Pain Proposed mechanism of action in pain Drug Opioid NE 5HT NMDA K NaV Tapentadol Tramadol Amitriptyline ? Levorphanol Methadone Milnacipran Venlafaxine Ketamine Opioid = mu, kappa, or delta activity; NE = norepinephrine reuptake inhibition; 5HT = serotonin reuptake inhibition; NMDA = N-methyl-d-aspartate glutamate antagonism; K = voltage gated potassium channel upregulation; NaV = voltage gate sodium channel blockade Ref Multiple Mechanisms of Action in Pain Proposed mechanism of action in pain Drug Opioid NE 5HT NMDA K NaV Tapentadol Tramadol Amitriptyline ? Levorphanol Methadone Milnacipran Venlafaxine Ketamine Opioid = mu, kappa, or delta activity; NE = norepinephrine reuptake inhibition; 5HT = serotonin reuptake inhibition; NMDA = N-methyl-d-aspartate glutamate antagonism; K = voltage gated potassium channel upregulation; NaV = voltage gate sodium channel blockade Ref MediCom Worldwide, Inc. 13

14 Multiple Mechanisms of Action in Pain Proposed mechanism of action in pain Drug Opioid NE 5HT NMDA K NaV Tapentadol Tramadol Amitriptyline ? Levorphanol Methadone Milnacipran Venlafaxine Ketamine Opioid = mu, kappa, or delta activity; NE = norepinephrine reuptake inhibition; 5HT = serotonin reuptake inhibition; NMDA = N-methyl-d-aspartate glutamate antagonism; K = voltage gated potassium channel upregulation; NaV = voltage gate sodium channel blockade Ref Multiple Mechanisms of Action in Pain Proposed mechanism of action in pain Drug Opioid NE 5HT NMDA K NaV Tapentadol Tramadol Amitriptyline ? Levorphanol Methadone Milnacipran Venlafaxine Ketamine Opioid = mu, kappa, or delta activity; NE = norepinephrine reuptake inhibition; 5HT = serotonin reuptake inhibition; NMDA = N-methyl-d-aspartate glutamate antagonism; K = voltage gated potassium channel upregulation; NaV = voltage gate sodium channel blockade Ref Multiple Mechanisms of Action in Pain Proposed mechanism of action in pain Drug Opioid NE 5HT NMDA K NaV Tapentadol Tramadol Amitriptyline ? Levorphanol Methadone Milnacipran Venlafaxine Ketamine Opioid = mu, kappa, or delta activity; NE = norepinephrine reuptake inhibition; 5HT = serotonin reuptake inhibition; NMDA = N-methyl-d-aspartate glutamate antagonism; K = voltage gated potassium channel upregulation; NaV = voltage gate sodium channel blockade Ref MediCom Worldwide, Inc. 14

15 Multiple Mechanisms of Action in Pain Proposed mechanism of action in pain Drug Opioid NE 5HT NMDA K NaV Tapentadol Tramadol Amitriptyline ? Levorphanol Methadone Milnacipran Venlafaxine Ketamine Opioid = mu, kappa, or delta activity; NE = norepinephrine reuptake inhibition; 5HT = serotonin reuptake inhibition; NMDA = N-methyl-d-aspartate glutamate antagonism; K = voltage gated potassium channel upregulation; NaV = voltage gate sodium channel blockade Ref Multiple Mechanisms of Action in Pain Proposed mechanism of action in pain Drug Opioid NE 5HT NMDA K NaV Tapentadol Tramadol Amitriptyline ? Levorphanol Methadone Milnacipran Venlafaxine Ketamine Opioid = mu, kappa, or delta activity; NE = norepinephrine reuptake inhibition; 5HT = serotonin reuptake inhibition; NMDA = N-methyl-d-aspartate glutamate antagonism; K = voltage gated potassium channel upregulation; NaV = voltage gate sodium channel blockade Ref Analgesic Synergy Additive analgesia Prolonged duration of effect Prevention of side effects Prevention of tolerance Prevention of dependence/diversion Ref MediCom Worldwide, Inc. 15

16 Gabapentin + Morphine RCT, double-blind, crossover design Four arms Gabapentin monotherapy (GBP) Morphine monotherapy (M) Placebo (P) Gabapentin + morphine (GBP-M) Results (n = 41, neuropathic pain) GBP-M resulted in lower pain intensity GBP (P <.001), M (P =.04), P (P <.002) Ref 21 Nortriptyline + Gabapentin RCT, double-blind, crossover design Three arms Nortriptyline monotherapy (N) Gabapentin monotherapy (GBP) Gabapentin + nortriptyline (GBP-N) Results (n = 45, neuropathic pain) GBP-N resulted in lower pain intensity GBP (P =.001) and N (P =.02) Ref 22 Sequential Multimodal Therapy Pre-operative gabapentin/pregabalin Pre-operative duloxetine Pre-operative nerve block Peri-operative wound infiltration Ref MediCom Worldwide, Inc. 16

17 Clinical Pearls Multidisciplinary team approach is preferable Pharmacists play a vital role on the pain management team Pharmacists possess unique knowledge of analgesics Multimodal therapy for pain results in: Decreased pain severity, duration, and chronicity Decreased pain-related disability Decreased medication-related side effects Decreased opioid burden Achieving Optimal Therapeutic Outcomes in Pain Management from a Pharmacist s Perspective Chris Herndon, PharmD, BCPS, CPE Assistant Professor Southern Illinois University Edwardsville Clinical Pharmacy Specialist St. Elizabeth s Hospital Belleville, Illinois References 1. Morlion B, et al. Multidisciplinary pain education program for chronic pain patients: Preliminary evidence for effectiveness and mechanisms of change. Curr Med Res Opin Jun 22 [Epub ahead of print]. 2. Loeser JD, et al. Multidisciplinary pain management. Seminars in Neurosurg. 2004;15: Flor H, et al. Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain. 1992;49: Bennett MI, et al. Educational interventions by pharmacists to patients with chronic pain: Systematic review and meta-analysis. Clin J Pain May 21 [Epub ahead of print]. 5. Gagnon L, et al. Optimizing pain relief in a specialized outpatient palliative radiotherapy clinic: Contributions of a clinical pharmacist. J Oncol Pharm Pract Apr 13 [Epub ahead of print]. 6. Swick ER, et al. Providing optimal care to the chronic pain patient in the community pharmacy. Poster Presentation at the 2010 American Society of Health-Systems Pharmacy Midyear Clinical Meeting; Anaheim, CA. 7. Fine PG, et al. Meeting the challenges in cancer pain management. J Support Oncol. 2004;2(suppl 4): Portenoy RK, et al. In: Lowinson JH, et al., eds. Substance Abuse: A Comprehensive Textbook. 4th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2005: MediCom Worldwide, Inc. 17

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