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28: Pharmacist pain management tips

In this episode I’ll share how I approach a “Pharmacy Pain Consult” at my hospital.  I’ll discuss how I titrate opioid doses when the patient has risk factors for respiratory depression. I’ll also share the 4 most common fixes to inadequate pain management.

I was talking with Andrew, one of our listeners in the free group I created for Pharmacy Nation on slack.com. Andrew reminded me it has been a while since I shared how to get into the slack group on the podcast. Imagine a place where pharmacists can collaborate and communicate with each other in real time to improve patient care. Free. That is the goal for the Pharmacy Nation group I have started on slack.com. This group is a supplement to existing pharmacy email list-servs and forums. I belong to several pharmacy list-servs and forums but the response time is often slow, and listserv replies are often not made publicly or are lost in “out of office” messages. This Pharmacy Nation group on slack.com allows for real-time conversations to occur involving pharmacists anywhere. If you want to join Andrew, myself, and the over 60 other pharmacy nation members in the slack group, head over to pharmacynation.org. I hope to see you there!

Pharmacy pain management service

The hospital I work at is a 450 bed community hospital.  We have 5 clinical pharmacists who provide pain management services.  As the residency year progresses, we also train our 4 PGY-1 residents to provide the same service.  A phone call or a written order for “pharmacy pain management” from a nurse or physician/provider can serve as the trigger to have a pharmacist evaluate a patient for better pain control.

I’ll let anyone fool me once

Pain is subjective in nature. It can be difficult to determine when a patient is truly in pain and when they are seeking the effects of opioids because of addiction.  I give each patient the benefit of the doubt when I encounter them the first time.  Just because one patient “burned” you and was drug-seeking doesn’t mean the next one is – always approach each patient with a fresh perspective.

Who am I? Why am I here? Who is the patient? Why are they here?

I use these 4 questions at the start of any consult to make sure I am focused on my role in solving patient problem(s).

Here are the steps I take at the beginning of the consult:

1. Locate and review the order for the consult and progress notes.

2. Thoroughly review the patient’s history of present illness, past medical history, allergies, home meds, current meds and other pertinent information.  I pay special attention to patient specific risk factors that may limit/prohibit certain analgesic interventions:

– Concurrent benzodiazepine or other sedative medication use
– Sleep apnea
– Obesity
– COPD
– Smoking
– Renal failure
– Multiple co-morbid conditions
– Advanced age

3. If they are available, I talk with the nurse and/or requesting physician to clarify what are the goals of care for the patient.

4. I review pre and post medication pain scores for the current pain regimen.  I’m looking to make sure that the post medication pain rating is checked about an hour after a dose was given.  Otherwise the pain scores may not be reliable.  For example, if the medication lasts 4 hours and the pain score was recorded 6 hours after a dose, I can’t use that to judge how well the regimen is working.  Pain score reductions of 30-50% are clinically meaningful.

Interview the patient

I start my patient interview off by explaining that my goal is to make sure they are satisfied with their pain relief and that everything possible is being done to control their pain.  After explaining the 0 to 10 pain rating scale to the patient, I ask the patient to rate and describe their pain.  Then I’ll ask the patient what their comfort goal is, or what level on the pain scale they are hoping to achieve.  This goal will be my target. The goal may be different for different activities (laying in bed vs. walking, etc.).

Determine the mechanism of pain

Next, I’ll try to determine the mechanism of the patient’s pain.  Doing so will help select the appropriate therapies for the patient.

Click here for a chart on determining the mechanism of pain

[tboot_table strip=”yes” border=”yes” condense=”yes” hover=”yes” cols=”Pain Mechanism,Character,Examples,Treatment Options” data=”Somatic, Usually well localized and constant; aching / sharp / stabbing,Laceration

Fracture

Burn

Abrasion

Localized infection or inflammation,Heat/Cold

Acetaminophen

NSAIDs

Opioids

Local anesthetics (topical or infiltrate),

Visceral, Not well localized; can be constant or intermittent; generalized ache / pressure / or cramping / can be sharp,Muscles/Spasm

Colic or obstruction (GI or renal)

Sickle cell

Internal organ infection or inflammation,NSAIDs

Opioids

Muscle relaxants

Local anesthetics (nerve blocks),Neuropathic, Can be localized (ex: / dermatomal) or radiating / can also be generalized and not well localized; burning / tingling / electric shock / lancinating,Trigeminal

Postherpetic

Postamputation

Peripheral neuropathy

Nerve infiltration,Anticonvulsants

Tricyclic antidepressants

Muscle relaxants

NMDA antagonists

Neural/Neuraxial blockade

“][/tboot_table]

Check for these 4 common fixes to pain management issues

1. Missing/suboptimal adjuncts – Tylenol, NSAIDs, Lidoderm patch, gabapentin, etc.  Often these can make a meaningful difference if used in the correct type of pain.

2. Suboptimal breakthrough opioid dosing compared to long acting regimen – for example a patient on oxycontin 80 mg po bid won’t get breakthrough relief from 5 mg of oxycodone. Typically 10-20% of the total daily opioid dose given at an appropriate frequency is needed for breakthrough pain (ex: 15 mg for moderate, 30 mg for severe breakthrough pain every 4 hours prn).

3. Are the orders actually being followed? Sometimes the RN needs education/reassurance that the orders are safe and appropriate for the patient.

4. For a patient refusing opioids by mouth (po) that the MD wants to transition to po, have the order state that “IV only to be given 1 hour after po if po ineffective”. If all caregivers are on the same page this can be a good way to get the patient started on a po regimen.

Opioid dose titration tips

If I feel the opioid dose should be increased, I follow these guidelines:

Short Acting Opioids:

– For Moderate pain, increase dose by 25-50%
– For Severe pain, increase dose by 50-100%
– Evaluate risk for respiratory depression/over sedation
– Re-assess for further increases in 2-4 hours rather than the next day

Long Acting Opioids:

– When initiating or increasing a long-acting opioid, start or increase by 50-100% of the total breakthrough dose given over the previous 24 hours
– Evaluate risk for respiratory depression/over sedation
– Re-assess for further increases no sooner than 24 hours for MS Contin or OxyContin and no sooner than 72 hours for Methadone or Fentanyl Patch

What to do if the patient has risks for respiratory depression

The main risk factors for respiratory depression I look for are:

– Concurrent benzodiazepine or other sedating medication use
– Sleep apnea
– Obesity
– COPD
– Smoking
– Advanced age

If the patient has risk factors that concern me, I use 2 strategies to manage their pain safely:

1. Titrate in smaller increments (ex: 25% increase instead of 50-100%) – It is easier to give more than to take it back!

2. Use continuous pulse oximetry – It is cheap and non-invasive and can be done anywhere in the hospital!

Wrap up

After I have evaluated the patient, I’ll determine what changes should be made to their current pain regimen.  I first make my recommendations verbally to the provider who consulted me, then I leave a detailed progress note. Check out episode 19 for how to write a pharmacy progress note.  If it is appropriate I leave in my note what the next step(s) should be. I’ll follow-up with the patient as needed.

Further reading

For a great review of pain management read chapter 93 of Hospital Medicine: Just The Facts.  In addition you can view my pain management resource page at pharmacyjoe.com/pain.

I’ve teamed up with Audible to offer you 2 free audiobooks.  You can take advantage of this special offer at pharmacyjoe.com/book.


If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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