Roles and disparities of clinical pharmacy

A conversation about the role of community physicians and pharmacists in opioid stabilization, and how the COVID-19 pandemic reveals clinical disparities.

Pages 65-66

This discussion is part of a new conversation series led by Editors Jeff Gudin, MD, and Jeffrey Fudin, PharmD, in honor of PPM 20th anniversary of publication. A condensed transcript follows. Navigate to the audio file.

Dr Fudin: Suzanne, we have served on many committees together and I am delighted to have you on this series. Let’s start by looking at your professional background. How did you come to pain medicine?

Dr Nesbit: Well, like a lot of things in life, it was an opportunity. Just a few years out of pharmacy school, I was asked to teach rotating medical staff in the oncology department about pain management and opioid management and the care of cancer patients with pain…. My interest grew from there, eventually moving into a Pain Management / Internal Medicine position.

Dr Gudin: Much of your work since then has been to develop and review pain management protocols, which help shape appropriate practice. What were your main lessons?

Dr Nesbit: Well, that has certainly changed a lot in recent years in the face of the opioid crisis. I see this in all aspects of patient care, both inpatient and outpatient, not only in terms of patient care, but also in how we have to educate ourselves as healthcare professionals, to take care patients and educate them.

Patients are very afraid of opiates and do not want to take them, even when they are clinically indicated. Our whole approach has therefore evolved. We thought that opiates were the only tool in our toolbox and that we could use them in perpetuity. What we are learning is that, as with all drugs, we need to think about the safe and rational approach to opioid use. More importantly, the opioid crisis has forced us to think about multimodal approaches and understand that pain is complex, and therefore our approach to how we deal with pain must also be complex.

Looking ahead, however, we need to be careful in responding to the opioid crisis and balance our approach so that we don’t go back to the days when we reserved opioids only for dying patients, which we are already seeing. We need to keep good, robust patient care focused on outcomes and safety metrics.

Dr Fudin: You were on the CDC task force that explored best practices for prescribing opioids, and you wrote about post-surgical opioid prescribing and related topics. What did you find most surprising about your research?

Dr Nesbit: There was a dearth of literature and data on post-surgical opioid prescribing. When we started to look at what was appropriate for specific surgeries, we initially thought it was one size, which clearly was not. The other aspect, particularly in the CDC’s Opioid Estimates Working Group – which was a 6-month engagement reviewing prescription claims data – was that it depended on who claims data and what you might get out of it. For example, if you are looking at claims data, you should make sure that it also includes the CMS (Medicaid, Medicare) patient population.

On top of that, there was not a lot of literature on the most appropriate pain management for individual procedures. Much of what we have done is the result of consensus of experts and expert groups and the formulation of those recommendations. Now we need to test them to make sure they are appropriate and that we are getting good results.

The other key issue we found was what our patients were doing with all these drugs that we were prescribing… some didn’t take them or get rid of them, they just clung to them.

Dr Fudin: Let’s explore this topic further in terms of the importance of opioid stabilization, including reconciliation and the role of the pharmacist from the time the patient leaves the hospital, to working with the community pharmacist, and so on. …

Dr Gudin: From a doctor’s perspective, there is such sensitivity around opioids. Most states have now adopted a 3-day, 5-day, or 7-day rule for acute prescribing and I see surgeons in my own facilities saying to patients, “Look, here is your bottle of 30 tablets, 40 tablets or pills. – do not call me when they are exhausted. ‘

At Suzanne’s point. I think we have gone a little too far. There are patients whose pain improves within 2 or 3 days and they no longer touch their opioids after that. And there are patients who start with chronic pain, who may need a little more attention for longer periods of time, whether that means opiates or not.

I think the clinical pharmacist has played an incredibly important role. Doctors can see patients for a few minutes at a time, whereas a pharmacist has typically known these patients for years and understands their co-morbidities, concomitant medications, and can be an important part of the healthcare team when they are in need. is about communicating with the patient and the clinician. on current needs.

Dr Nesbit: I absolutely agree. From a pharmacist’s perspective, it is essential that hospital pharmacists bridge this gap with our colleagues in the community. Just as patients typically have more than one physician on their healthcare team, we are entering a period when patients also need more than one pharmacist. This would be an inpatient or outpatient clinical pharmacist able to share information and work towards common goals with patient and community pharmacists. This is the only way to optimize medications across the entire healthcare continuum.

As an example, I’m part of the Pain Neuroscience Resource Team at Johns Hopkins, which is a pharmacy and nursing collaboration for patients in post-surgical neuroscience. We help manage the acute postoperative pain of their inpatients, but we also move them to their discharge order and discharge regimen for pain.

Much of this work involves educating the patient about what the dump regimen involves, whether it is opiates, muscle relaxers, acetaminophen, and how all of these work together. We help them understand and optimize their pre-discharge pain medication regimen so that they have the smoothest transition possible. Otherwise, this is where patient care falls through the cracks – in these intersections or transitions of care.

Dr Gudin: We would be remiss if we didn’t talk about COVID-19 and how it affects patients with pain who may already have underlying issues with sleep, anxiety, or depression, and who have pills on hand. hand at home. How has the landscape changed for you?

Dr Nesbit: Really, it’s an evolutionary response. Telemedicine has gone from zero to almost 100% in a matter of weeks, which presents challenges and opportunities, but what really comes to light very quickly is our disparities. There are patient populations that have been vulnerable before and now this vulnerability is even more glaring because they don’t have the technology or they don’t live in areas with high-speed internet … and language services that they need become really crucial when you’re on a TV and trying to get an interpreter on a call. In the future, I think there will be a role for telemedicine; as others have said, it will be difficult to put the genie back in the bottle.

On the inpatient side, we are seeing more and more patients coming in due to their substance abuse disorder who cannot get treatment, even if they want to sign up. It is therefore another population of vulnerable patients.

Over the past few years we have focused on opioid management … but we are now looking at opioid conservation strategies so that we can ensure an opioid supply for COVID-19 patients who are ventilated and require high opioid use . We see so many different aspects that this pandemic has brought to our practice that no one could have imagined just a few weeks ago.

Dr Gudin: As part of this series, we always ask guests what they would say to young residents and fellows who pursue pain management.

Dr Nesbit: Pain management is a fascinating field and pharmacists are essential – it is a great path. Make sure you know how to incorporate pharmacogenomics into your practice, as I think it will become more imperative in the future. In addition, we need to have good clinical pharmacists who are trained not only in pain medicine but also in addiction medicine. Having an eye on the future for that would be beneficial.

Suzanne Amato Nesbit, PharmD, FCCP, BCPS, CPE, is part of the Palliative Care Services and Pain Neuroscience Resource Teams at Johns Hopkins Hospital in Baltimore. She is a clinical specialist in pain management and palliative care in the Department of Pharmacy. Dr Nesbit is a faculty member in the Department of Oncology and the Center for Drug Safety and Effectiveness at the Bloomberg School of Public Health, Johns Hopkins, as well as the Schools of Pharmacy at the University of Maryland and the University of Notre Dame. Lady of Maryland. She has practiced pain management for over 30 years and is a Certified Pharmacotherapy Specialist and Certified Pain Educator. During her tenure at Johns Hopkins, Dr. Nesbit has been involved in several healthcare system pain research protocols and initiatives, including serving as Co-Chair of the Johns Hopkins Hospital Pain Management Committee and as an appointed member of the CDC’s Opioid Prescribing Task Force. She is the past president of the American Society of Health-System Pharmacists.

Last update on: November 16, 2020

20/20 with Peter Staats, MD: The Future of Pain Medicine

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