by Andrea Jarzynski, Pharm.D., pharmacy practice resident, and Ashley Thomas, Pharm.D., pharmacy practice resident, Aleda E Lutz Veterans Affairs Medical Center
A recent report issued by the Institute of Medicine found that 100 million Americans suffer from chronic pain. The International Association for the Study of Pain defines chronic pain as “pain that persists beyond normal tissue healing time, which is assumed to be three months.” Types of chronic pain include musculoskeletal, somatic, visceral and neuropathic. Multiple medication classes exist to treat pain, and patients may require more than one medication for effective pain control. Common medication classes include nonsteroidal anti-inflammatory drugs, opioids, tricyclic antidepressants, antiepileptic drugs and selective serotonin-norepinephrine reuptake inhibitors. Opioid analgesic prescriptions have greatly increased to more than 200 million, nearly a three-fold increase in the past 20 years. This increase in prescription count has led to a rise in patients experiencing adverse events such as falls, constipation, respiratory depression and even death.
Nationally, deaths from prescription analgesic overdoses have more than tripled since 1990, with 100 people dying every day from such an event. In Michigan alone, there are 12.2 overdoses per 100,000 people. Opioid analgesics are becoming more readily available, with 107 narcotic prescriptions written for every 100 Michigan residents. Recreational use of these medications is also becoming more popular. In 2010, more than 12 million Americans admitted to using a narcotic for nonmedical reasons. Non-opioid pain medications, like tramadol, are also being abused more frequently. In recent years, epidemiological studies have shown an increase in tramadol abuse, diversion and overdose. After many states preemptively tightened regulations on tramadol, the Drug Enforcement Administration recently designated tramadol as a Schedule 4 controlled substance under the Controlled Substances Act. This designation took effect on Aug. 18, 2014.
Because of the increased risks and consequences for opioid misuse and abuse, there are many large advocacy groups calling for more responsible opioid prescribing. Nationally, the Centers for Disease Control and Prevention proposes seven state legislative strategies to help battle the prescription drug epidemic. They include physical examination required for prescribing, patient identification (ID) required for dispensing, tamper-resistant prescription forms, pain clinic regulation, prescription drug limits, prohibition of “doctor shopping”/fraud and providing immunity from criminal charges for people seeking treatment of an overdose. Michigan currently enforces two of the seven recommendations (physical examination required for prescribing and patient ID required for dispensing).
The Michigan Automated Prescription System (MAPS) is a useful tool employed by providers and pharmacists to identify pharmacy/physician “shopping” and to prevent opioid misuse. There are currently 37 states that have a prescription monitoring system in effect. Pharmacies and dispensing prescribers are required to report any dispensed controlled substances to MAPS. Previously, the dispensing agency only required reporting to MAPS on the 1st and 15th of every month, however, on July 1, 2014, daily reporting was initiated. Health care providers and personnel have the ability to request a MAPS report after they are registered through the state of Michigan.
Chronic pain management requires a multidisciplinary approach. A comprehensive clinical pain team may include a physician with specialty in pain, along with other health care providers such as a pharmacist, mental health provider, physical therapist or substance abuse specialist. Pharmacists can play an important role in specialized pain management teams, including opioid conversions, opioid tapering, identifying and managing adverse events, and educating patients on their goals of therapy and expectations for treatment. A recent study shows that patients with chronic pain show great satisfaction with interventions and overall effectiveness of care provided in a multidisciplinary approach that includes a pharmacist.
There are many opportunities for specialty certification in pain management. The American Society of Pain Educators offer a certification as a Pain Educator (CPE) and the American Academy of Pain Management (AAPM) offers a General Credentialed Pain Practitioner (GCPP) open to all health care professionals. For CPE credentialing, a pharmacist must dedicate 10 percent of their work experience to providing pain-related education, along with 30 credit hours of pain-related continuing education (CE) credits. Obtaining a GCPP credentialing requires 100 hours of CE with 50 hours pertaining to pain. An American Society of Health-Systems Pharmacists (ASHP) Postgraduate Year (PGY) 2 residency can also be completed in the area of pain management after the completion of a PGY 1 residency. In addition, ASHP offers a tiered educational initiative for providers wishing to improve their knowledge in pain and palliative care.
With the rise of opioid analgesic abuse, health care professionals need to ensure the safe medication practices of their patients. The addition of a credentialed pharmacist to the team or the implementation of specific prescribing protocols may be first steps to effective and safe pain management. Working together as a health care team may be the best way to rectify this ever-growing problem.
References available upon request from MPA office.