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Pharmacists' Roles on the Pain Management Team, Fall 2014 Fall 2014, Volume 8, Issue 2 Canadian Pharmacy > Research > Health Policy > Practice > Better Health Pharmacists’ Roles on the Pain Management Team harmacists are an important resource for managing pain in their patients, in order to both optimize treatment and Pprevent the unintended consequences of potent analgesics. While the role of pharmacists in pain management was first addressed inthe Translator Summer 2012 edition1, this rapidly evolving area of pharmacy practice has generated a number of innovative models that highlight the unique role of the pharmacist. As Canadian pharmacists embrace expanded scopes of practice, there is an opportunity to specifically leverage their services to assist patients in managing their pain. This issue of the Translator highlights four different approaches to enhanced involvement of pharmacists in the management of chronic pain: n Pharmacist-led management of chronic pain: a randomized controlled exploratory trial from the UK n A pharmacist-initiated intervention trial in osteoarthritis n A pharmacist-led pain consultation for patients with concomitant substance use disorders n The impact of pharmacists in translating evidence to patients with low back pain 1 The Translator, Summer 2012, 6:3 Pharmacist-led management of chronic pain in primary care: results from a randomized controlled exploratory trial Bruhn H, Bond CM, Elliott AM, et al. Pharmacist-led management of chronic pain in primary care; results from a randomized controlled exploratory trial. BMJ Open 2013;3:e002361. Issue: In the UK, an estimated 80% of medication review of each patient’s medical chronic pain sufferers still report pain after Pharmacist prescribing and records, followed by a face-to-face consul- four years of follow-up.1 Most patients refer reviewing pain medication may tation. Patients had completed a pain diary to primary care providers for pain manage- be effective in improving to inform the consultation. Any required ment, where the mainstay of treatment prescriptions for medicines were issued by remains pharmacological therapy with pain-related outcomes the pharmacist and a treatment plan was analgesics. Suboptimal prescribing may agreed upon. In the review arm, pharma- account for the poor pain control and the outcomes of non-medical (including cists conducted a paper-based medication adverse patient outcomes seen commonly pharmacist) prescribing versus treatment review focused on pain-related medications in pain therapy. As medication therapy as usual provided by the general practi- before creating a pharmaceutical care plan experts who have a thorough understand- tioner (GP). that detailed recommendations for medi- ing of the polypharmacy regimens involved cation changes. The plan was passed to in chronic pain management, pharma- A solution: The outcomes for patients with the patient’s GP for implementation but no cists prescribing for pain could drastically chronic pain, managed by one of two phar- prescribing was done by the pharmacist. In improve outcomes for chronic non-cancer macist-led models of care, were compared the treatment as usual (TAU) arm, patients pain (CNCP) patients. However, there has with standard GP care. Pharmacists in the received standard care from their general not yet been a rigorous comparison of prescribing arm conducted a paper-based practitioner. Outcomes were the physical The Translator is an initiative by the Canadian Pharmacists Association to support the knowledge translation between pharmacy practice research and health policy. Each issue selects a number of pharmacy practice research articles, briefly summarizes them and discusses the health care policy implications. These articles are submitted by researchers who have a strong desire to support evidence-based health care policy and best practices. Pharmacist-led management of chronic pain in primary care: results from a randomized controlled exploratory trial (cont.) and mental component scores of the SF-122 and anxiety (p=0.007). Both were also arm. However, based on subscale findings, and the Health Utilities Index as primary significant between groups (p=0.022 and it is clear that the improvement in overall endpoints, and the overall Chronic Pain p=0.045, respectively). CPG score was due to improvements in Grade3 (CPG) and the subscales in terms intensity of pain, not pain-related disability. of pain intensity and disability scores and Implications: This was the first explor- Most patients were within normal range for depression and anxiety scores (HADS atory randomized controlled trial (RCT) HADS scores at baseline, but the findings scale)4 as secondary endpoints. to specifically assess pharmacist-led man- suggest better outcomes at follow-up in After six months, there was significant agement of chronic pain compared with the prescribing group. The lack of statisti- improvement in overall CPG grade in the usual GP care, and the first to assess clinical cal difference in SF-12 general health scores prescribing (p=0.003) and review arm outcomes of independent pharmacist pre- across arms could mean the intervention (p=0.001) but not in the TAU arm. There scribing compared to medical prescribing. had no impact on general health, or that were no statistically significant improve- The results suggest that pharmacist pre- there was insufficient power to detect the ments in SF-12 physical component scores scribing (and possibly pharmacist review effect in this study. Lastly, despite good (PCSs) other than for the TAU arm, but alone) may be effective in improving pain- self-reported adherence to medication at significant deterioration was also noted related outcomes and be acceptable to baseline, pharmacists improved pain out- in the TAU arm for SF-12 mental compo- both patients and most professionals. CPG comes in the prescribing arm. If not due to nent scores (MCSs) (p=0.002) and HADS findings showed a graded effect across improved adherence, this may have been depression (HADS-D) scores (p=0.03). the three study arms, showing discrimina- due to changes in medications and/or par- HADS scores showed a statistically sig- tion with both direction and strength of ticipant education about optimal timing for nificant improvement within the prescrib- improvement, suggesting maximum ben- administration of analgesic medicines. ing arm for both depression (p=0.022) efit for those in the pharmacist prescribing Background or research methods: In the also a supplementary prescriber qualifica- to take part in this study. As this was UK, pharmacists can qualify as indepen- tion, in which pharmacists can prescribe an exploratory pilot trial to inform a sub- dent prescribers (similar to having addi- within an agreed clinical management sequent definitive RCT, no formal power tional prescribing authority in Canada) plan in partnership with a doctor and calculation was undertaken. Due to the with the legal authority to prescribe any patient (similar to collective prescribing nature of the intervention, participants prescription-only medicine within their agreements in Quebec). Only indepen- were not blind to their group allocation. perceived areas of competence. There is dent pharmacist prescribers were eligible 1 Elliott AM, Smith BH, Hannaford P, et al. The course of chronic pain in the community: results of a 4-year follow-up study. Pain 2002;99:299–307. 2 Ware JE, Kosinski M, Turner-Bowker DM, et al. User’s manual for the SF-12v2 health survey. 2nd edn. QualityMetric, Incorporated, 2009. 3 Von Korff FJ, Ormel M, Keefe J, et al., Grading the Severity of chronic pain. Pain 1992;50:133-49. 4 Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361-70. Call for Research Abstracts and Innovative Practices 2015 PHARMACY PRACTICE RESEARCH Researchers and practitioners are invited to submit abstracts* on cutting- edge pharmacy practice research to be considered for oral and poster presentations at the Canadian Pharmacists Conference 2015. PHARMACY PRACTICE INNOVATION Pharmacists who have implemented innovative ideas or services in IMPORTANT DATES their pharmacies are invited to submit abstracts to be showcased at January 5, 2015 the Canadian Pharmacists Conference 2015. Deadline for submission of abstracts May 28–31, 2015 Canadian Pharmacists Conference 2015 in Ottawa, ON Submission guidelines and additional information are available on our website at www.pharmacists.ca/conference or by contacting [email protected] *Abstracts may be submitted in English or French. 2 © 2014 Canadian Pharmacists Association Pharmacist-initiated intervention trial in osteoarthritis: A multidisciplinary intervention for knee osteoarthritis Marra CA, Grubisic M, Cibere J, Grindrod KA, Woolcott, JC, Gastonguay L, Esdaile JM. Cost-Utility Analysis of a Multidisciplinary Strategy to Manage Osteoarthritis of the Knee: Economic Evaluation of a Cluster Randomized Controlled Trial Study. Arthrit Care Res. 2014 June; 66 (6): 810-816 Issue: Osteoarthritis (OA), the most fre- pharmacy for over-the-counter (OTC) med- quent form of arthritis, is a degenerative Patients experience quantifiable ication, of which 78% specified a pain relief joint disease. It is progressive and irrevers- medication. Display cards on pharmacy ible, defined as a loss of articular cartilage benefits from interprofessional counters recruited 52% of participants, coexisting with joint pain and dysfunction.1 collaboration amongst pharmacists, while a supplemental 38% gained infor- Ten per cent of men and 13% of women mation about the study through
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