Crossno 1Presentation by Scott Strassels, PharmD, PhD. A clinical pharmacist with Optum Hospice Pharmacy Services, a partner of Kindred  

Medications, while prescribed to promote healing and symptom relief, often have unintended effects that can hinder care goals. All clinicians must be able to recognize medication-related problems and reach out to pharmacists as necessary.

In Scott's presentation, he sought to help the audience understand the roles of pharmacists in pain and palliative practice and understand how analgesics are chosen based on type and severity of pain.

In interdisciplinary palliative and hospice care teams, pharmacists provide symptom management and reduction, act as a medication use resource, and control distribution and compounding. They make recommendations, monitor and avoid adverse events, consider cost and insurance coverage, support transitions of care, educate and train, provide scholarship and conduct research.

lorraine and ralph 2Scott used Lorraine and Ralph's story as a case study for the audience. Scott said Lorraine and Ralph's case was complex, and it was important to look at  family preferences, the types of the pain that are occurring and pain intensity  when deciding how to treat the pain. For example, Scott said we don't really know if there's a significant risk of use disorders, but her husband Ralph expressed concerns based on his past experience, which is important to consider.

How is pain intensity measured? Pharmacists and clinicians often focus on the 0-10 pain scale, but we have to remember that pain is subjective and incredibly complicated. Sometimes, patients are asked to report their pain visually on a line using a pen or pencil, but not all patients are able to hold a writing instrument.

Scott prefers the "OLD CARTS" scale, a mneumonic device that helps fully characterize pain

O:Onset
L:Location
D:Duration

C:Characteristics
A:Aggravating Factors
R:Relieving Factors
T:Temporal Variation
S:Severity/Intensity
(F):Functional Status 

Audience 1There is also the Wong-Baker scale of faces. This introduces an emotional aspect to measuring pain, which is both an advantage and a disadvantage. It's a good idea to take into account a patient's emotions; however, associating happiness with no pain and associating sadness with pain does not always tell the full medical story.

To understand pain, both the intensity and type (and duration) must be considered. There are several categories for pain , and many of us have heard pain described as acute and chronic. Acute pain is usually of limited duration and tends to decrease with time. Chronic pain lasts for an undefined period and "lasts longer than we might otherwise expect," said Scott. Acute and chronic pain sometimes overlap.

Treatment duration is not determined by type of pain. "It is not the duration of pain that characterizes chronic pain, but the inability of the body to restore normal functioning."

audience 2It's important to remember that in some cases, we trade in pain for pain. Someone who gets a knee replacement is trading in osteoarthritis pain for the pain of recovery following joint replacement surgery.

Pain can also be described as somatic or visceral pain, which has to do with the location of the origination of the pain. Neuropathic pain refers to nerve pain.

Cancer pain is a unique category as well. Roughly 75% of pain in cancer patients comes from the neoplasm itself, and pain also comes from treatment.

After describing the types of pain that there are, Scott asked the audience to categorize Lorraine's pain. Scott said her issues are complex and that more information is needed to accurately assess.

So how do pharmacists make prescribing decisions? Whenever possible, we want to give people medication by mouth. Other methods of administration can be painful, with erratic absorption. Ideally medicine should be done "by the ladder," on a schedule and with special attention to detail for the individual.

What about acetaminophen and NSAIDs, which are ubiquitous in our society?  

audience 3We still don't have a perfect understanding for the role of acetaminophen, but these medications are commonly used for mild pain, and pharmacists and clinicians like that they don't affect platelet aggregation or inflammation. It's often considered a first line for arthritis pain, even though it isn't indicated for that kind of pain. Acetaminophen is ineffective for acute low back pain. Lower dose limits are currently being debated.

What about NSAIDs, like Aleve? They are considered very effective, but they're wonderful for some people and not good for others. As with all medication, NSAIDs use should be tailored to the individual. They can be good because they might allow someone to prescribe less of an opioid if they're taking an NSAID too.

What exactly are opioids?  

Opioids are the cornerstone of treatment for moderate to severe pain. They are often categorized by receptor activity and chemical structure. Opium is isolated from the latex of the poppy plant, and 25% of pharmaceuticals are currently derived from plants.

audience 4Overall, opioids are similar in their ability to provide pain relief. As long as side effects are manageable and the person is responding well, the dose can be increased as needed. Scott also talked about considering a patient's individual medication metabolism, and explained which opioids are indicated in hospice depending on the patient's medical condition and pain type.

When people think about prescribing opioids, there are short-acting and long-acting opioids. Unless the patient has pain that is severe and very hard to control, we generally try to avoid mixing multiple medications and intense opioids. Clinicians consult a 3-step analgesic ladder to assess the appropriate opioid (or non-opioid) to prescribe for the pain at hand.

Scott ended his discussion by encouraging every attendee to reach out to their pharmacist if they ever have any questions about their medications. Kindred's pharmacy support teams in attendance were encouraged to reach out to Scott with any questions.

 

Please continue to follow the Clinical Impact Symposium 2016 on the Kindred Continuum and on Twitter @KindredHealth.

*Each year the Kindred Clinical Impact Symposium focuses on a topic to enhance clinical practice in the post-acute continuum and to maintain Kindred as a leader in clinical excellence. This eighth symposium focuses on pain management across the continuum. At this week's symposium, held in Louisville, Kentucky, national speakers discuss these topics broadly, while internal speakers bring it home to Kindred attendees from across the country.