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Involve pharmacists in a pain management team
Hospitals need a pharmacist who specializes in pain management on board, although this model hasn't taken off as a trend as quickly as many experts in the field believe it should.
"There really wasn't a lot of recognition of health systems even needing pain services until the 1980s with the hospice movement," says Virginia Ghafoor, PharmD, a clinical pharmacy specialist in pain management at the University of Minnesota Medical Center Fairview in Minneapolis and a clinical pharmacy specialist in pain/palliative care at Fairview Ridges Hospital in Burnsville, MN.
As hospice and palliative care programs began to grow, there was an evolution in health systems offering pain management services, she adds. "In the 1990s, we started seeing the impact of the aging population having pain problems, including degenerative joint diseases, neuropathic pain, and other types of chronic pain," Ghafoor recalls.
This trend led to the development of new drugs for treating neuropathic pain, including gabapentin (Neurontin) and pregabalin (Lyrica), she notes. "So, what has happened is there's a growing demand to have people who are specializing in chronic pain for both pain management and for a multidisciplinary approach," Ghafoor explains.
Pain is a significant topic, says Lee Kral, PharmD, BCPS, a clinical pharmacy specialist in pain medicine at the University of Iowa Hospitals and Clinics in Iowa City. Pain medication management involves psychosocial, substance use, regulatory, and diversion/abuse issues, making it a very complex pharmacy specialization, the experts say. While every pharmacist should have a basic knowledge about pain medicine, there's also a need for pharmacists who are specialists in pain medicine, Ghafoor says.
Hospitals increasingly are asking pharmacists to start pain services, and the pharmacists' role in pain services needs to grow, but there also needs to be more resources budgeted to train pharmacists in this practice, she says. "A lot of pharmacists have learned about pain medicine on the side, and they really don't have a lot of formal training," Ghafoor adds. "They need more structured training before they take on a service like this all by themselves."
The problem is that pharmacists traditionally receive only a few hours of pain medicine education as students, so most of the training comes post-graduation, notes David S. Craig, PharmD, BCPS, a clinical pharmacist specialist and residency director in psychosocial, palliative care, and integrative medicine at Moffitt Cancer Center in Tampa, FL. "There's a big movement in hospitals to incorporate palliative care in end-of-life care and pain management, and this is one of those areas where hospital pharmacists can get involved with patients," he says.
However, the pharmacists will need to be trained in pain medicine, Craig adds. Hospital pharmacists often are too busy to obtain the training on their own, and hospitals typically do not invest in creating a role for a pharmacist pain medicine specialist, he says. "We have a pharmacy pain management program here, and there are two others in the United States," Craig says. "So, that makes three pain management pharmacy programs in the United States."
Hospitals are recognizing the need for better pain management, however.
Christopher Herndon, PharmD, BCPS, an assistant professor at Southern Illinois University Edwardsville, says, "What you find is that hospitals have been forced into looking at pain management in a much more serious light because of recent Joint Commission standards," he says. "This makes it a perfect storm for pharmacists to be involved," he adds.
The American Society of Health-System Pharmacists (ASHP) featured an all-day session on pain management at its 43rd Mid-Year Clinical Meeting, held Dec. 7-11, 2008, in Orlando, FL. Craig, Ghafoor, Herndon, and Kral spoke about pain management at the conference.
ASHP is working to develop pain medicine residency standards for pharmacists, Craig says. "ASHP is trying to highlight and inform hospital pharmacists who are out of school and practicing now to give them the tools they need to incorporate these standards into their own practices," he says. "But this is only for the pharmacists who are motivated and interested in the pain medicine field; it'd be nice if there were standards for all hospital pharmacists."
The University of Iowa Hospitals and Clinics has about 100 pharmacists, including many who are involved in internal medicine and patient care issues that also involve pain management, Kral notes. "But what's unusual is we actually pay one pharmacist, me, to do nothing but pain management full time," Kral says.
At the minimum, it's important to have a pharmacist involved in the pain management team, Kral and other experts say. Hospitals are beginning to create teams of pharmacists and nurses to run inpatient pain and symptom management programs, and a number of larger teaching institutions now have pharmacists involved in their pain teams, Herndon says.
However, this change hasn't translated into creating pain management pharmacy specialists, as is ideal, he notes. "We did a large survey of hospitals three or four years ago, asking what is the largest thing precluding hospitals from assigning a pharmacist either full-time or part-time to pain management, and it all came back to resources and budget," Herndon explains. "The doctors are all for it and the directors are for it, but it's a soft cost service because we can't bill for it."