E4: Pain Management and the Role of the Pharmacist

This is OnePath with Metrohealth, your toolkit for helping to combat the opioid epidemic as a member of the medical community with empathy, mindfulness, and a big-picture perspective. I’m Libbey Pelaia, educator within Metrohealth’s department of Opioid Safety. Thanks for joining us.

This week on OnePath, we’re talking about pain management and the role of the pharmacist-- and in particular, how the workflows of doctors and pharmacists can intertwine in order to create the highest quality of care for a patient, and the highest level of opioid safety possible.

As a case study, we’ll be talking to Dr. Mike Harrington, the director of palliative care clinical services here at MetroHealth, and Dr. Amanda Benedetti, pharmacy specialist in pain management and opioid stewardship in the Office of Opioid Safety.

Dr. Harrington explains that palliative care is a relatively new speciality in the field of medicine, emerging around the year 2000.

MH: Palliative care is a specialty of care that's mainly focused on working with patients with advanced serious illnesses, often chronic debilitating, cancer, advanced dementia, stroke patients, degenerative diseases, so pretty people with pretty advanced and symptomatic illnesses. And basically trying to focus on trying to relieve their symptoms as much as possible, but also the stress of the illness, not just for the patient, but also for the family, as they're all working as a unit to get through these complex medical illnesses.

As you can likely imagine, pain management, and ultimately opioids, are a big part of Dr. Harrington’s work-- and that’s where some adjustments have taken place in his practice.

MH: Being the one who's been prescribing since early 2000s, there's been a changing body of literature as well as practice. So some of the teachings that we were getting in the 2000s, probably didn't hold salt over years, such as many things in medicine. So, we've had to just adjust, who's the best candidate for treatments. What are our goals for the treatments? Are there maximum doses or not maximum dosages and especially learning which pain syndromes are going to be opioid responsive and which ones really are not as responsive as we thought they originally would be.

Remember last episode when we talked about the peer review process? Dr. Harrington was reviewed by the office of opioid safety and found the process to be, in his words...

MH: ...very helpful. When the office was first opening up, they were doing peer reviews on most of the providers. Obviously, based on the practice I have, a large proportion of patients with opioids, so I had a peer review. It was done by three peers, it was nice to have some clinical support for the care that we were providing, meaning that they felt that the care was clinically appropriate, but also gave you some tips and viewpoints on ways to make it as safe as possible for patients and just ideas on trying to make sure you keep monitoring systems up to speed and make sure that you use the tools that we have at MetroHealth through electronic medical records, et cetera, to keep that as up to date as possible.

It was after his peer review experience when his collaboration with Dr. Benedetti came into play.

MH: I work closely with Dr. Amanda Benedetti, who is one of the opioid safety pharmacists here at Metro, and she's been a great support and advocate hopefully for our services as well as, especially for our patients. So they've been involved in a lot of support for the patients as far as literature, literature for the clinics, also gives, I think, a place for clinicians to go with questions, resources, and it's also added a lot of legitimacy to increase in medication assisted treatment programs, monitoring programs, and just really generalized supports for a field of medicine that's under a lot of scrutiny and pressure as a provider these days.

We asked Dr. Benedetti to talk about where her process begins when working with a given patient. She shared that a lot of work goes in prior to even meeting them.

AB: I spend a lot of time researching the patient and reading through their chart and finding out as much information as I can regarding their pain history, when it started, what they've tried, has that worked, has it not worked? I also will review the state's prescription monitoring plan and see their history of how they fill their opioid or their controlled substance prescriptions. Then finally, when I do see a patient, when they come in to meet with me, I introduce myself and explain why they are there seeing me. I do a lot of education in regards to that.

After discussing the patient’s pain history and getting the chance to ask each other any questions they may have, they’ll start discussing pain management options.

AB: And then we discuss their pain history and confirm or deny whatever I have found in the chart so that they can expand on that information. Or if I have any additional questions, they can help me understand how they've gotten to where they are. After we discuss all of that, we will talk about different options that they can try. The ultimate goal is typically trying to reduce the amount of opioids that they are taking. So whether it is suggesting some non-medications that may be helpful for them, or maybe they're on a medication, but it's not at its recommended dose or maximum dose and trying to really optimize that treatment. And then, like I said, eventually the goal would be to begin tapering or decreasing their opioid medications.

Dr. Benedetti’s work impacts Dr. Harrington’s prescribing choices before, during, and after interacting with the patient. Sometimes they work in tandem one-on-one with patients, sometimes Dr. Benedetti is sending Dr. Harrington information on a patient’s pain history before they come in, but each time these two are working together, it’s because a patient was referred to them due to their complex symptoms-- symptoms that may currently be mismanaged by ill-fitting therapy modalities. Dr. Harrington loves having Dr. Benedetti as a resource.

MH: Having Amanda there is fantastic, because she'll often go and even ahead of me, and she's has a lot of experience in medical management of pain, and she'll be able to actually establish rapport with the patient, review the medications and make sure that we're making decisions based on meds they're really taking as well as she's got a lot of expertise in history taking to help let us know what patients have used successfully, what they've struggled with. If the patient's going to need some pain agreement, she's going to help me with that, because she has the technology there with her.

It it really is brings to the table, what we're all trying to do, which is to maximize non-opioid therapies first, or at least add adjunctive therapies, to keep doses to the lowest and most effective regimens and levels that we can.

So, she's able to do that in person and we'll often see the patient either together or I'll come out after I've interviewed them and examined them and we'll sit down and say, okay, what do you think? Do we increase the medicine? Do they need more medicine? Do they need an antidepressant? Do they need a neuropathic drug? Do they need therapy or should we get this person to the surgeon right away? So, it's a real nice collaborative approach to what's the best way that's individualized for each patient.

We then have to start bringing patient's medications down as they are healing, which is the whole goal. She's helpful as far as just reiterating or using as a resource, we can discuss together, what would the proper rate of weaning be or is it appropriate? Is this someone who's going to need a medication long term? And just having someone who is familiar with that is nice.

Dr. Benedetti and Dr. Harrington shared their perspectives on patient reactions to their style of caregiving.

AB: They are often in that mindset, "I've been taking this for many years and nothing has happened. Why would something happen now?" And then I go on to explain how 10 years ago, they were 10 years younger. Now they're 10 years older, which our body changes and so a slight change in how our kidneys are working could cause that medication to build up in our system and cause a problem. So there's a variety of different things that we need to be aware of.

MH: Probably the biggest thing is that from patients is they get instant education on their medication. They get instant validation of their medical problems. They get to talk about side effects. They get to talk about why we're having this consult to begin with. So, I think [inaudible 00:14:37], they really see it as another member of the team, which again only enhances their care and feels like they're getting the best care possible.

AB: One of the things that I think is really important with having the patient hear the same message from multiple people is they are often more easily convinced. So if I meet with a patient and I tell them, "Hey, we would really like to decrease your opioids by 10% to make you more safe. This is what I have in mind. I'll send it to your provider and you guys can discuss." And then they see their provider in a week or two. And the provider brings that up to them. One, they've had some time to think about it and then two, hearing it from their provider can really ensure that, "Okay, now two people have told me this. This is probably what I should be doing."

Getting a patient to fully believe that cutting back on opioids is in their own best interest can be a challenging, sometimes long road. Dr. Benedetti says that a lot of that resistance is due to fear.

AB: Oftentimes these patients have chronic pain. They have been on opioids for a long, long time, and they often have the mindset of, "If it's not broke, why fix it or why change it? It's working for me. It's been working for me for many years. Why do we have to change this?" So I think the two big things that I will discuss with patients, one is just providing education, letting them know that when they were started on these medications, 10, maybe even 15 years ago, that was more of an accepted treatment. But over the years, we have more evidence and recommendations have changed. Just like any other disease state, when we get new studies and new evidence, our therapies can change.

Education is key. The other thing that I think is really important for patients is setting expectations. Oftentimes the first time I meet with a patient, I may really not have any specific recommendations or if I do, I let them know, "We're going to work with these non-opioids first to try to maximize them. And then maybe the next time that we meet, then we can talk about decreasing the opioids." So it's really building that trust and that they don't think that I'm coming in just to take away their medications, but I'm really working with them to make them feel better and to make them safer.

Dr. Benedetti says that understanding the history of a patient’s pain is one of the most important things a provider can do to facilitate the highest quality care.

AB: I know a lot of providers today will inherit patients from other providers who have retired or moved away and maybe on these higher doses of opioids that they're not familiar or not comfortable prescribing. So really learning that patient's history and getting to know them as well as checking all of the different information that we have available to ensure that patients are using their medications safely and appropriately. So checking that State Prescription Monitoring Program database, checking back on past pain management panels, which is like a urine toxicology screen to make sure that the medications that are prescribed are in the patient's system and nothing is in there that shouldn't be and like I said, just building that relationship with the patient so that there is a nice trusting relationship.

She says that another very important tool is a controlled substance agreement.

AB: It states that the patient understands that there are risks that go along with taking these types of medications, that they understand, and that they accept that risk and that both the provider and the patient have specific things that they will do to ensure the safe use of these medications. I guess one other really important thing is to consider the use of Naloxone and providing prescriptions if appropriate or maybe in all situations, because you never know when that Naloxone may be needed.

Dr. Harrington has three important touchstones that he keeps in mind while evaluating a patient for pain management therapies.

MH: I think trying to stay at least on the initial evaluation, trying to stay objective as possible. When someone starts to complain of pain, it's easy to shut that down because I think a lot of us as providers haven't had a lot of pain, so it's a difficult one to understand what a patient may be going through. But I think in doing that, I think really having a comfort in clearly identifying, what the source of the pain is, is it a physical pain? Is it a nerve pain? Is it a bone pain? What's making it worse? Is there existential stuff in their family? Are they depressed? Are they stressed out? Are they exhausted?

And so, you can really narrow the therapy as targeted as possible. And if that requires a medication, that's great, if not, trying to find the right interventionalist, et cetera, if needed or other therapies. Next would be short term followup. So, I mean, it is a commitment to these patients. If you're going to prescribe them a medication, you have to be responsible for the drug that you prescribe as well as making sure that they get appropriate, follow up with you, and make sure that they're getting an appropriate result.

Then I think third is, what's your treatment goal? if it's diabetes it's an A1C less than seven. If it's oncologists, it's to see the cancer to get less on your cat scan. So again, what is the treatment goal? Is it going to be function? Is it going to be a pain score? Is it going to be, I want to get them through chemotherapy and 35 radiation treatments in a row? Get them on the table and back every time. So you need to have some treatment goal, so you know what you're doing is effective, otherwise it's easy to forget or at least lose track of when do I adjust the medicines up and then also, when do I start to bring them back down and try to get them off of them when appropriate.

Dr. Harrington says that he’s feeling hopeful about the future of opioid use in pain management, and that’s due to work like what’s being done by the office of opioid safety.

MH: I think we're seeing that there's definitely a role for these medications. And again, aggressive education for providers is being done and that's going to have to continue to be enhanced and done, especially in a trainee level, so they feel comfortable with the medication, but also understand when and how to use them. I think also the improvement in education when you're struggling with a patient, whether it's their pain itself, whether it's their behavior, are they doing aberrant behaviors? We have a lot more resources than we did before in the past, people to ask, people to get help and I think that's huge.

Next time on OnePath with Metrohealth…

We talk with Dr. Chong Kim of the Pain and Healing Center about non-opioid pain management tactics.

OnePath with Metrohealth is a production of Evergreen Podcasts, produced, written, and engineered by Hannah Rae Leach and mixed by Sean Rule-Hoffman. Special thanks to Mike Tobin, Karolyn Tibayan, Joan Papp, Joya Riffe, and the entire Department of Opioid Safety in making this show possible.