Alternative to Opioid Prescriptions for Continuous Chronic Pain

Sondra Adkinson, PharmD, DAIPM, CPE, believes education is one of the best medicines. As a clinical pharmacy specialist at Bay Pines VA Healthcare System's outpatient integrative pain clinic, she's tasked with helping the team assess whether opioid therapy is appropriate for patients who may have been taking these drugs for months or longer. Often enough, it's not. She will meet with patients to discuss a new approach, one that involves shared decision making, individualized goals focused on function, and more active patient participation in their own care.

"I may be the first on the team to educate the patient on the risks of long-term opioids and that it may be unrealistic to expect to be pain free with a drug-only plan," Adkinson said. "This message is a difficult one to initiate with upset patients who feel they have been cut off from their pain medications. However, after I've heard and addressed their concerns and fears, they welcome the new information and an integrated wellness approach."

Adkinson's work is part of the VA's (U.S. Department of Veterans Affairs) model of patient-centered care. As part of the model, patients attend a program called Pain School, where they learn from pharmacists, psychologists, physical therapists, and recreational therapists who identify alternative treatments, provide resources, and educate patients about the risks of opioid-only therapies for chronic noncancer pain.

All of her skills and training are put to good use at the VA, Adkinson said. "Having an advanced scope of practice and collaborating with a pain physician allows me to practice as a midlevel in the pain clinic. I'm able to use my skills as a certified pain educator to break down the walls of failed therapies and misconceptions, while validating veterans' pain and supporting the safe and effective use of medications in their pain management journey."

Shifting currents in pain management

The last 15 years have seen a lot of changes in pain management, with the perspective of opioids as a panacea for pain giving way to a backlash against them as the nation fights a lethal wave of misuse and addiction. Indeed, opioid prescriptions have begun to decline: According to a paper published online in the Journal of Pain Research last February, the total number of dispensed opioid prescriptions fell 2.2% in 2014, 6.8% in 2015, and a projected 2.9% in 2016. Since 2010, prescriptions dispensed for extended-release opioids of greater than 90 morphine-mg equivalents have dropped 34%.

Yet reining in prescriptions has its own set of problems, said Nicholas Hagemeier, PharmD, PhD, associate professor at Bill Gatton College of Pharmacy at East Tennessee State University in Johnson City.

"The decrease in morphine-equivalent prescriptions can be a good thing or a bad thing, depending on your perspective. You have to consider the demand as well as the supply. Many patients who are struggling with opioid use disorders will seek out another way to meet that demand. That is one reason we're seeing heroin and fentanyl deaths."

Prescribers are feeling pressured by regulatory and credentialing agencies as well as prescribing guidelines, Hagemeier added.

"Primary care physicians are reluctant to address pain with opioids. There's a sense of 'the DEA is watching me, my board might be watching me,'" he said. "And there are perceptions of pressure from the guidelines, even if they carry little legal weight."

Some states have passed legislation that emphasizes the pharmacist as the last defense against illicit opioid abuse. For example, in Ohio, pharmacists and pharmacies are prohibited from dispensing or selling more than 90 days of opioids, although there are no restrictions on the amount in the prescription. However, the onus is still on prescribers, said Ernest Boyd, PharmD (Hon), MBA, CAE, executive director of the Ohio Pharmacists Association in Columbus. "Pharmacists [here] are seeing virtually no prescriptions for 90 days or more. Most are for 30 days. The majority of the enforcement changes have still been on prescribers, like having physicians sign up with the prescription drug monitoring program [PDMP]."

Adkinson said that some of the new laws do not account for the clinical implications of setting limits on opioid prescribing and dispensing.

"They're making arbitrary lines in the sand without considering the patient's needs or plan of care. [Setting an arbitrary number of pills] can lead to drug hoarding and other maladaptive behaviors that put patients at risk of suicide or overdose."

Working with prescribers

As medication experts, pharmacists are well positioned to help prescribers find alternatives to opioids. The trick is getting prescribers to collaborate, said Hagemeier.

"We've run into pharmacists who've had trouble getting in touch with prescribers. There's often an intermediary like front office staff, a nurse, or a voice-mail system, and the pharmacist will leave a message that goes unreturned," Hagemeier said.

Hagemeier encourages pharmacists to be mindful of their approach. "If you introduce yourself and build rapport, it will go a long way. Say you're taking care of a mutual patient, you have a question about one of the prescriptions the patient brought in, and you're wondering if the prescriber can help you."

Hagemeier urges pharmacists to consider the prescriber's perspective when trying to collaborate. "Offer prescribers a way you can make their lives easier, like running PDMP reports, assisting in monitoring patients on prescription opioids, or doing screenings with opioid risk tools to determine abuse potential in patients and sharing results with prescribers."

Boyd said pharmacists should be prepared with suggestions for therapeutic alternatives. "When looking at the addictive nature of various opioids, there is a declining amount of abuse potential going down to codeine. Pharmacists can encourage physicians to use less addictive opioids. It's even better if over-the-counter drugs can be used."

There may come a time when the pharmacist notices that a provider's prescribing patterns don't meet best practices or fall well outside the norm. In such cases, there's only so much a pharmacist can do, said Boyd.

"The hope is that the pharmacist might reach out and try to assist them in understanding the benefits of using the PDMP and staying within the guidelines," Boyd said. "Admittedly, that is a very difficult conversation. If a physician is writing excessive quantities or inappropriate dosing, the pharmacist will have to call the state medical board, who can remind the physician of what the rules are."

Working with patients

Pharmacists are in an excellent position to help chronic pain patients navigate changes in their care plans, but they should remember to tap into their compassion when opening up a dialogue, said Carla D. Cobb, PharmD, BCPP, clinical associate professor in the department of pharmacy practice at University of Montana in Missoula and pharmacist with RiverStone Health in Billings.

"It's important to talk to patients and educate them about the risk of using opioids and the risk of addiction. I don't know that we always do that very well. We as pharmacists have it so ingrained that it's dangerous and these patients are drug-seekers. The kind thing is to say, 'I'm worried about you and the risks involved in taking this medication,'" Cobb said, adding that pharmacists shouldn't hesitate to explain the symptoms of addiction to patients. "There is so much stigma around substance use disorders, it's possible to forget that patients may not know either the risks or what the signs are."

Medication counseling is particularly important for patients with comorbid mental health disorders, Cobb said. "There is an increased risk of overdose in people who are on sedating antipsychotics or benzodiazepines. Let the patient know that you noticed they're taking these medications."

Getting patients help

Community pharmacists who suspect a patient has a substance use disorder should offer the patient information on where to get treatment, said Carla D. Cobb, PharmD, BCPP, clinical associate professor in the department of pharmacy practice at University of Montana and pharmacist with RiverStone Health, both in Billings. "Have a list of detox centers, treatment programs, names, addresses, and phone numbers in the pharmacy for patients who need help getting off these medications."

Depending on the pharmacy's location and staffing, maintaining such a list can be a challenge, but Nicholas Hagemeier, PharmD, PhD, associate professor at Bill Gatton College of Pharmacy at East Tennessee State University in Johnson City, has a solution: "Advanced Pharmacy Practice Experience students can keep it updated. It's a great learning opportunity."

Unfortunately, the wave of opioid misuse and diversion has given rise to a crop of fraudulent treatment centers and sober houses, some of which spring up and disappear in as little as 6 months, robbing payers and leaving patients worse off in their wake. Headlines have focused on Florida and California as prime targets, but scam clinics can pop up anywhere, and resources need to be vetted carefully.

"Use resources in physicians' offices, and meet with a therapist who knows who is reputable and who is not. For patients who have insurance, insurance companies will have a list of treatment providers they have worked with and will be able to give you a list of substance treatment programs," said Cobb.

Working in the community, pharmacists stand poised to be a force for prevention, said Ernest Boyd, PharmD (Hon), MBA, CAE, executive director of the Ohio Pharmacists Association in Columbus.

"Pharmacists are the most knowledgeable about drugs and their actions, and they ought to be out there educating in their communities and schools, spending time with youth groups, and engaging them in an age-appropriate way to become more resistant to taking the medications to begin with," Boyd said. "Pharmacists can also give parents quite a bit of guidance. It has been shown that when parents talk to their children about it, that can help stop some of the misuse."

Pharmacists can tap into Generation Rx, an educational program developed and supported through a collaboration among the Cardinal Health Foundation, the Ohio State University College of Pharmacy, and the APhA Foundation. The Generation Rx website (GenerationRx.org) offers resources, videos, and information that increase public awareness of prescription medication abuse and encourage health care providers, community leaders, parents, teens, and college students to actively work to prevent prescription drug abuse.

To foster a two-way conversation, Cobb suggests asking questions like, "Do you need naloxone in your home? Do we need to educate your family or others in the home? How might we get you off of some of these medications?"

According to Cobb, pharmacists should find out if the patient has ever been in treatment for a substance use disorder. "Whenever a physician prescribes an antibiotic, they'll ask if the patient has any allergies. But they also need to ask if the patient has a history of substance abuse, and pharmacists should ask the same question before dispensing the prescription."

Boyd highlighted the need to discuss what patients will do if they don't need or take all of the medication they're prescribed. "More than 60% of people who are addicted say they started by getting drugs out of medicine cabinets, so when we dispense an opioid, we should ask patients what they will do with the rest. Mention that their kids or grandkids can get into the drugs, and offer to help them figure out what to get rid of if they bring all of their medications [from home] to the pharmacy."

Despite a pharmacist's most conscientious effort to be mindful and compassionate, some patients may become upset or angry when they encounter a barrier or delay to accessing their pain medications, such as prior authorization. Cobb cautions pharmacists to remain calm.

"Validate the patient's feelings, and let them know you understand they're frustrated or angry and you'll try to help them out, make calls, and see what's needed," Cobb said. "Try to remain nonjudgmental. Whatever the patient is feeling or dealing with is difficult. They are having a traumatic thing happening in their lives. Be sympathetic to that."

Although the vast majority of patients who present prescriptions for opioids do not have substance use disorders or plan to divert their medications, chances are that sooner or later pharmacists will run into a patient whose history or behavior sends up a red flag. Ultimately, pharmacists must fall back on their training and maintain their corresponding responsibility to prevent misuse and diversion. Cobb advises pharmacists to prepare for this by talking to people with substance use disorders who are in treatment.

"Attend an AA [Alcoholics Anonymous] meeting, listen to people who have been through it, and try to understand a patient's point of view on what it's like to struggle with an addiction," Cobb said.

Helping patients taper off opioid medications can be a challenge at times, but the effort is well worth it, Adkinson said. She recalled a patient who went to Pain School and began complementary therapies.

"He said he got his life back. Although he still has some pain, now he has some strategies to manage it, and he said it's like a veil has been lifted and he's come out of the fog."

Reference

1. J Pain Res. 2017; 10 : 383-387

Article Info

Footnotes

Terri D'Arrigo, reporter

Identification

DOI: https://doi.org/10.1016/j.ptdy.2017.08.022

Copyright

© 2017 American Pharmacists Association. Published by Elsevier Inc. All rights reserved.

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