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Pharmacists Role In Pain Management

Katrina Lynn, Pharm DPSHP Annual Assembly: October 12, 2017

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Presentation Objectives

Briefly discuss Geisinger Health System and the use of Pain Management Pharmacists in patient care

Analyze statistics of the opiate epidemic Describe important aspects of implementing a pain

program Discuss beneficial outcomes Geisinger has seen since

starting its own Pain MTM clinics

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Pharmacists can play an important role in chronic pain management

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Pain free is an appropriate goal for chronic pain management patients

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The best way to treat chronic pain is with medications alone

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Geisinger Health System

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MTDM Program Timeline

Anticoagulation

AnemiaChronic Kidney

Disease

Metabolic Disorders

Chronic Noncancer Pain

Medically Complex Children

Hematology/Oncology Heart Failure

Multiple Sclerosis Psoriasis

AnemiaInsulin Pumps

Intracranial stents

Hepatitis CAsthma

Neuroimmune modulators

Familial Hypercholesterolemia

Chronic Obstructive Pulmonary Disease

RheumatologyCrohns DiseaseUlcerative Colitis

1996 1999 2003 2012 2013 2014 2015 2016 2017

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Program Goals

Patient Safety

Identify and treat high-risk population

Decrease emergency room visits and hospitalizations for pain/overdose

Mitigate risk for opioid abuse/diversion

Reduce risk of intentional or accidental overdose

Patient Focused Care

Educate patient

Work with patient to establish realistic goals and exit strategy

Enhance patient functionality

Improve overall quality of care and patient satisfaction

Treatment Optimization

Minimize use of chronic high dose opioids

Actively incorporate opioid sparing adjuvant medications

Collaborate and utilize available interdisciplinary and community resources

Decrease overall cost of care

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Physician Feelings on Opioids

25% of physicians feel

confident managing the opioids they

prescribe 60% of physicians state time

limitations in the exam room inhibit opioid prescribing

from being a priority

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Opiate Prescriptions Dispensed in U.S.

https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse

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Opiate Consumption in U.S.

1212http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.htm

Nonmedical use of Prescription Pain Meds

1313NIH. Overdose Death Rates. Revised December 2015. http://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

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Powerful Medications

In 2010 38,329 people died of a drug overdose in the US 22,134 involved pharmaceutical drugs

16,651 deaths were due to prescription opioids

Prescription Drug Overdose 75% of deaths are from opioids (3 of every 4

deaths)

"Drug Overdose Deaths up for 11th Year." United Press International. N.p., 20 Feb. 2013. Web. 28 July 2017.

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Breaking Down the Numbers

16,651 deaths x 825 = 13,737,075 people abusing prescription opioids

That is equal to the entire population of PA, Washington DC, and half of Vermont (2013 data from census.gov)

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What does a High Risk patient look like?!

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PA Annual Drug-Induced Death Rate: 2005

Nmalaw skey@pennlive.com, Nick Malaw skey |. "Mapping Pennsylvania's Worsening Heroin Crisis." PennLive.com. PennLive.com, 02 Mar. 2016. Web. 28 July 2017.

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PA Annual Drug-induced Death Rate: 2013

Nmalaw skey@pennlive.com, Nick Malaw skey |. "Mapping Pennsylvania's Worsening Heroin Crisis." PennLive.com. PennLive.com, 02 Mar. 2016. Web. 28 July 2017.

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A multidisciplinary approach is essential for optimal pain control

Because pain affects all aspects of your life, medications alone are not the answer. We need to address the physical, emotional, social and spiritual aspects of your pain as well.

Physical

Social

Emotional

Spiritual

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Setting Expectations

Complete pain relief is not reasonable, nor is expecting to be able to return to the same degree of activity that the patient had previously.

Treatment is not just about pain relief, its also about improving the patients ability to do more on their own.

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Setting Expectations

Realistic and Shared Goals:

Decrease pain (intensity, frequency) Decrease suffering Enhance self control

Improve function Improve sleep

Improve mood/decrease distress Increase activity (work, recreation, etc)

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Expectations of Patients

Signing a Medication Use Agreement (MUA) with physician

Urine Toxicology Screens are expected at least once to twice per year and are random

Pill counts at every visit

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The Four As of Opioids

Analgesia Does the patient have effective pain relief?

Adverse effects Are they severe, limiting, or are they controlled?

Activity Evidence of increased function with opioids? meeting activity

goals? Aberrant Behavior

Screen/monitor

Not getting the right answer on 4As? Then STOP!

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Discontinuing Opioids

Patients who exhibit instances of medication aberrant behavior (e.g., broken Med Use Agreement)

Patient preference No improvement of function or developing tolerance

despite 2-3 dosage increases Experiencing intolerable adverse effects

E.g., excessive fatigue, sedation, falls, CNS toxicity, opioid-induced hyperalgesia

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How to Taper Opioid Therapy

Keep the instructions uncomplicated Weekly, bi-weekly, or monthly intervals Written instructions

Slow taper if possible 10% reduction at a time (10-25% acceptable) One size does NOT fit all for opioid tapering

Some patients taking high doses (> 200mg MED) may tolerate more rapid tapers at first

Close follow-up and withdrawal symptom control are important

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Opioids + Benzodiazepines AVOID!

Opioid overdoses usually have polysubstance involvement

Risk of overdosage increases with benzodiazepines Benzodiazepines have high physical dependency

potential

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Plan

Managing chronic pain requires a comprehensive approach that might include: Physical therapy Cognitive behavioral therapy Titrating medication regimen Exercise programs

The goal is to optimize pain relief, improve outcomes, and reduce dependence on opioids.

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MTDM Pain Management: Outcomes

Internal retrospective analysis of the Geisinger MTDM Pain program for patients with chronic, non cancer pain compared: Patients managed by MTDM Pain pharmacists, practicing under

the guidance of a pain physician Non-pharmacist-guided patients not enrolled in MTDM Pain

ProgramIncluded: Patients on high doses of Morphine Equivalents per day Patients on short acting and long acting opioids Patients on Methadone

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MTDM Pain Management: Outcomes

2014 GHS Pharmacy Resident project results showed 52% decrease in Morphine Equivalent per day (MEQ/D) with control group showing a 16% INCREASE in MEQ/D for GHS patients over the past 18 months.

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Pain Pharmacists Reduce Amount of Opioids

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*Dose is in Morphine Milligram Equivalents (MME) per day

Chart1

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Non-MTM

MTM

Time (months)

Dose in Milligrams

Sheet1

Non-MTMMTM

Index Date4750

6 Month Visit5030

12 Month Visit5925

To resize chart data range, drag lower right corner of range.

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Pain Pharmacists Reduce Emergency Visits

Chart1

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2010

277

Non-MTM

MTM

Percent

Sheet1

Non-MTMMTM

Index P = 0.442219

6 months P = 0.022010

12 months P = 0.04277

To resize chart data range, drag lower right corner of range.

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Secondary Outcomes: Med Use Agreements

Chart1

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Non-MTM

MTM

Number of patients (%)

Medication use agreements P = 0.007

33% (N=33)

61% (N=70)

61% (N=70)

Sheet1

Non-MTMMTM

Medication use agreements3361

To resize chart data range, drag lower right corner of range.

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Chronic Pain-National LevelCondition US Patient Population Annual Cost of CareChronic/Persistent Pain 1 100 million $560-$635 billionDiabetes 25.8 million $245 billionCoronary Artery Disease 16.3 million $108.9 billionStroke 7 million $53.9 billionCancer 13 million $124.6 billion

1. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Institute of Medicine Report. 2011

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Pain Cycle: Living with Pain can be Difficult

Sleep Pain and Anxiety make it hard to sleep. Lack of sleep makes

pain worse and decreases energy

MoodChronic pain and the limits it puts on your life can lead to

depression, anger, and anxiety. These feelings make coping

with pain harder

ActivityPain and lack of energy make it

hard to be active. Lack of exercise worsens pain.

Energy Coping with pain drains energy. Lack of energy makes it hard to

be active and stay in shapePain

Normal Activities

RelationshipsEating Habits

Finances

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Questions?

email: kalynn2@geisinger.edu

Recognition:Eric Wright, PharmD, MPHLeeann K. Webster, RPh, CACP CDELaney Jones, PharmD, MPHJessica Andersen, PharmD

Pharmacists Role In Pain ManagementKatrina Lynn, Pharm DPSHP Annual Assembly: October 12, 2017Presentation ObjectivesSlide Number 3Slide Number 4Slide Number 5Geisinger Health SystemMTDM Program TimelineProgram GoalsPhysician Feelings on OpioidsOpiate Prescriptions Dispensed in U.S. Opiate Consumption in U.S.Nonmedical use of Prescription Pain MedsSlide Number 13Powerful MedicationsBreaking Down the NumbersWhat does a High Risk patient look like?!PA Annual Drug-Induced Death Rate: 2005PA Annual Drug-induced Death Rate: 2013A multidisciplinary approach is essential for optimal pain controlSetting ExpectationsSetting ExpectationsExpectations of PatientsThe Four As of OpioidsDiscontinuing OpioidsHow to Taper Opioid TherapyOpioids + Benzodiazepines AVOID!PlanMTDM Pain Management: OutcomesMTDM Pain Management: OutcomesPain Pharmacists Reduce Amount of OpioidsPain Pharmacists Reduce Emergency VisitsSecondary Outcomes: Med Use AgreementsChronic Pain-National LevelPain Cycle: Living with Pain can be DifficultSlide Number 35