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Pain management model has safety advantages
Developing inpatient pharmacy model is challenge
Hospitals could improve the overall care of patients who are admitted for surgery, palliative care, or for diseases that result in chronic pain if they employ a pharmacist to assist with medication utilization and develop defined medication plans for the more complex cases, an expert suggests.
"There are a lot of safety issues associated with opioids and other narcotics," says Virginia Ghafoor, PharmD, a clinical pharmacy specialist in pain management at the University of Minnesota Medical Center-Fairview in Minneapolis. The health system, which is the largest in Minnesota, has nine hospitals and the university medical center.
"Pharmacists monitor medication doses and review the combined medications used with patients to follow safety practices for preventing over-sedation and overdosing of patients," Ghafoor adds.
Ghafoor works at the University of Minnesota Medical Center, which has 800 beds, and on Mondays and Thursdays at a community hospital that has 180 beds in a pain and palliative care service model that includes pharmacy support.
"My challenge has been to look at the development of an inpatient pharmacy model in the community hospital setting," Ghafoor says.
"Our university has a unique model for pain service, and the university has three different pain services, including a general pain service with an outpatient clinic where they see acute and chronic pain patients," she explains. "Then there's a palliative care service that sees a lot of patients mostly with terminal diseases, and then there's an anesthesia service that sees patients who have an epidural."
The institution follows a model, called Mid-Level Practitioner Model for Pain and Palliative Care Services-Clinical Pharmacy Services, which is illustrated in a flow chart.
"I've been trying to see how a pharmacist could integrate into this model on an inpatient basis and help with activities that provide a more appropriate utilization of resources," Ghafoor says.
The pain services model suggests a variety of services a pharmacist could provide, including the following:
• Finding the right drug for the patient: "A lot of patients seeking pain management are really ambulatory, primary care patients and could be seen in a primary care setting," Ghafoor says. "So how many of them are coming through the emergency room with chronic pain needs that could be handled in an ambulatory care setting? We're looking at models to restructure that process."
For example, a pain service could develop a pain management plan for a patient with high opioid needs with the goal of reducing his or her emergency room visits.
"Opioid medications have to be adjusted for each patient," Ghafoor notes. "These doses are all individualized, and there are a lot of safety issues regarding that."
The front-line pain management staff check out a patient's pain medication history when the patient comes through the door, Ghafoor says.
"If a patient hasn't been on pain medicine before coming into the hospital then we have a whole different set of prescribing practices," she says. "Those who have not been on pain medication are at more risk of side effects."
Alternately, the patients who have been on pain medication may have pain control issues, Ghafoor says.
"Those patients will have higher opioid needs and have more difficulty controlling their pain," she says.
"Those patients can be very challenging because clinicians don't always recognize all the problems they've had with their pain and doses," Ghafoor adds. "So it's the job for the pharmacist right up front to make sure everything is checked out and we're using the right drug at the right dose for the patient."
On a pain management team, it often is the pharmacist who finds the right drug by assessing drug properties and the patient's medical condition.
• Improve safety and prevent drug interactions: A hospital pharmacist who specializes in pain management also could help alert hospital staff to potential side effects when palliative care or hospice patients are admitted and treatment is prescribed for droperidol. When combined with the patients' likely methadone use, droperidol could result in QT prolongation and cause a fatal heart problem, Ghafoor says.
Hospice patients typically are prescribed methadone because hospice reimbursement is low and the cost of some alternative treatments is many times greater than methadone, Ghafoor notes.
"The cost of methadone is 65 cents per day," she adds. "So if hospice or palliative care patients come into the ER, they're most likely on methadone already."
In addition, methadone is a much more difficult drug to dose correctly, so hospitals will need pharmacists' help with these patients, Ghafoor says.
"We've been working to have all clinical pharmacists work together to achieve National Patient Safety Goals around narcotic use both in the ambulatory and hospital setting," Ghafoor says.
"All of our patients are required to check orders for patient-controlled analgesia," she adds. "Pharmacists have to make sure the physician ordered doses appropriately."
• Help develop better compliance protocols: This ties in with safety issues, Ghafoor notes.
"Physicians cannot order large ranges of opioid drugs," she says. "They have to keep it within a two-fold range, and that's partially driven from the National Patient Safety Goals."
So if an order is outside of the two-fold range, the pharmacist has to call the physician to get it changed, Ghafoor adds.
Another compliance issue at the hospital system is a requirement that a pharmacist check a patient's opioid history when there is any Sentinel patch prescription of more than 50 mcg/hour, Ghafoor says.
"These patches are not to be used in patients who have never been on opioids prior to coming into the hospital," she adds. "If you put a patch on someone who isn't tolerant to opioids, the patient could become over-sedated and have life-threatening respiratory depression."
Sometimes a patient will come out of surgery and a patch will be prescribed without anyone having full knowledge of the patient's past opioid use, she notes.
"These situations come up, and the pharmacist has to talk with the physician about the safety issues regarding this, Ghafoor says.
• Educate patients and plan for follow-up monitoring: Pharmacists could educate patients before they're discharged through short visits that alert the patient about changes in their medications, Ghafoor suggests.
"You have patients who are on anticoagulation medications, and you have to tell them that you know they have acute chronic pain, but they can't take ibuprofen because it can increase their bleeding time," she adds. "We try to give patients a little bit of advice on medications that could become problematic."
Also, patients need some kind of medication follow-up at the outpatient site, Ghafoor says.
"We've been trying to develop some outpatient collaboration with primary care pain management clinics," she says.
Among the patients who will benefit from follow-up monitoring are those with pain as a primary problem and who are on a terminal progression with their disease, but they're not ready for hospice care, Ghafoor says.
"Those are the ones where I'll work with nurses on an outpatient model," she explains. "A lot of these patients will leave the hospital to go back home, but they want a connection with the clinician in the hospital because they won't have access to a lot of services outside the hospital."