From Assessment to Discharge: Pharmacists Drive Safer, Patient-Centered Acute Pain Management

As health systems continue to emphasize multimodal acute pain management, pharmacists play an important role in helping clinicians select therapies that are both effective and safe for individual patients. Although reducing unnecessary opioid exposure remains an important goal, experts caution that acute pain care should not be evaluated by opioid reduction alone. Instead, treatment decisions should account for the type and severity of pain, patient-specific risks, functional goals, prior opioid exposure, and the transition from inpatient or postoperative care to the outpatient setting.

In an interview with Pharmacy Times, Brandon Kasberg, PharmD, clinical pharmacy specialist in pain management and palliative care at UK HealthCare, discussed how pharmacists can contribute to patient-centered multimodal acute pain management. He addressed preoperative planning, pain assessment, opioid stewardship, the potential role of newer nonopioid analgesics such as suzetrigine, risk factors for persistent pain or prolonged opioid use, and pharmacist-led transitions-of-care interventions.

Pharmacy Times: As multimodal acute pain management becomes more widely adopted, what distinguishes a truly patient-centered multimodal regimen from simply combining several analgesic therapies? Beyond reducing opioid consumption, which clinical outcomes should be used to determine whether a regimen is successful?

Brandon Kasberg, PharmD: Ideally, acute pain management in a surgical patient begins in the preoperative phase, when patient-specific factors such as allergies, contraindications, drug-drug or drug-disease state interactions, thorough medication reconciliation, and conversations regarding past analgesic effectiveness and expectations for postoperative pain and function are discussed and determined. Intraoperative pain management strategies may also be discussed and planned for at this time.

However, acute pain management in a trauma patient or an emergent surgical case may not allow for as much preoperative planning. In this instance, a detail-oriented medical chart review is necessary to gain an overall understanding of the patient.

Postoperatively, or in the nonsurgical patient, a multidimensional pain workup is crucial in determining key factors that will guide the selection of pain-alleviating therapies. The PQRSTU method is one strategy clinicians can use to assess pain. Important considerations include whether the pain is mild, moderate, or severe; whether it is truly acute versus subacute or chronic; whether the patient is opioid-tolerant or opioid-naive; and the type of pain, such as nociceptive, neuropathic, or nociplastic pain.

Gaining this information preoperatively, when possible, and postoperatively helps clinicians tailor a safer and more effective multimodal regimen to the individual patient’s needs.

A key part of the pain assessment is determining the goals of therapy. These goals may include a pain rating or score, but they should also include functional outcomes, such as returning to baseline function or achieving an anticipated improvement. Typically, a 30% reduction in pain score on the 0-to-10 numeric rating scale is considered clinically significant, but most patients will benefit from tangible goals based on function.

Pharmacy Times: How should clinicians tailor multimodal acute pain regimens according to the cause and severity of pain, the procedure being performed, and individual factors such as age, kidney or liver function, gastrointestinal or cardiovascular risk, and concurrent medications?

Kasberg: Two key factors are the risk-benefit discussion and understanding which alternatives are available. The risk-benefit discussion should occur for any medication, not only opioids. Even medications such as acetaminophen and ibuprofen carry possible risks for certain patients.

For example, in mild pain, there are many options, including both pharmacologic and nonpharmacologic therapies. Therefore, clinicians do not need to immediately jump to a medication such as an opioid, which carries many risks and is not always well tolerated. Because there are many options at this point, selecting treatments that will be safe and effective is less challenging.

For acute pain that is moderate to severe, or expected to become moderate to severe, clinicians may need to use multiple tools from the pain management toolbox. We should not avoid medications such as acetaminophen or ibuprofen in these cases if they are not contraindicated and are appropriate for the type of pain the patient is experiencing, because they provide useful and unique mechanisms of action to target pain.

The addition of other agents, such as antispasmodics, neuropathic analgesics, and topical agents, may also be considered. If needed, options such as partial agonist intravenous opioids; full agonist, short-acting intravenous or oral opioids; intravenous N-methyl-D-aspartate antagonists; intravenous or oral sodium channel blockers; or peripheral or neuraxial techniques may be considered.

In summary, each agent should be evaluated for both safety in the individual patient and potential efficacy based on the information gathered about the pain experience. It is also important to consider that the pain experience may include physical, psychological, and social aspects that are uniquely treated with different modalities.

Pharmacy Times: Efforts to reduce opioid exposure can sometimes raise concerns about undertreated pain. How can clinicians practice responsible opioid stewardship while still recognizing when opioids are appropriate and necessary for acute pain?

Kasberg: This common challenge is best addressed through early discussions with the patient about pain expectations and goal setting. Recognition of the etiology of pain and when the pain type often responds to opioids should also guide this decision.

When opioids are initiated, close follow-up helps assess whether the goals of therapy are being met. This is easier to accomplish in the inpatient setting than in the outpatient setting. Follow-up also provides an opportunity to assess for adverse effects and conduct risk screening, such as use of the Opioid Risk Tool.

Acute pain is a condition in which opioids do have a place in therapy, particularly severe acute pain from surgery, trauma, or acute exacerbations of chronic illness, such as cancer or sickle cell disease.

Patients with severe acute pain for whom opioids are indicated should be started on the lowest effective dose, in combination with nonopioid or nonpharmacologic therapies, and with short-acting formulations, such as intravenous or immediate-release options. When determining the lowest effective dose, the clinical team must consider opioid tolerance from long-term opioid therapy, medication for opioid use disorder, such as buprenorphine or methadone, nonprescribed opioid use, or frequent hospitalizations during which opioids were administered.

Pharmacy Times: With newer nonopioid treatments such as suzetrigine entering clinical practice, where might these therapies fit within existing multimodal acute pain pathways? What evidence, safety considerations, drug interactions, access barriers, or other practical factors should pharmacists evaluate when determining their role?

Kasberg: The interest and progress in expanding our nonopioid analgesic repertoire is promising. With suzetrigine being the first newer agent to market, there is a lot of enthusiasm surrounding its use. Although pain clinicians should be excited to add this to the repertoire of analgesics, there are many considerations that must be evaluated before widespread use is adopted.

Current literature does not include robust data surrounding the heterogeneous patient populations that most pain clinicians encounter. As a pain management pharmacist, I also see additional barriers to using suzetrigine. In terms of efficacy, we do not have overwhelming data showing that this medication will be effective for many of the pain etiologies or conditions we encounter clinically.

When looking at safety considerations, many acute pain patients may be taking CYP3A-inhibiting medications or may have hepatic impairment. With short-term use, suzetrigine appears relatively safe; however, long-term adverse effects have not been as well established because it is a newer agent.

Major additional considerations include cost, access, and insurance coverage. Currently, cost-benefit has not been established, which prevents formulary inclusion for many inpatient institutions. Variability in insurance coverage also limits which patients may have coverage for the medication in the outpatient setting. As a patient transitions across clinical settings, such as from outpatient care to inpatient care, rehabilitation, and then back to outpatient care, access to the medication may vary.

Personally, I look forward to further research regarding new nonopioid analgesics and commend pharmaceutical companies for investing resources in this clinical area. I have seen off-label use of suzetrigine start to increase, along with the use of various manufacturer coupons. I am interested to see which patients may benefit from suzetrigine and how this medication shapes future nonopioid analgesic development.

Pharmacy Times: Which patients are most likely to experience persistent pain or prolonged opioid use following an acute pain episode, and what steps can pharmacists and other clinicians take early in treatment to reduce that risk, particularly among patients with previous opioid exposure or opioid use disorder?

Kasberg: There are many risk factors associated with persistent postoperative pain or prolonged opioid use. During the acute pain phase, a primary goal is to prevent subacute and ultimately chronic pain from developing.

The care team should set expectations for the patient’s postoperative or acute pain course early in the encounter. At that point, the pharmacist should review the patient’s current medications, including nonprescribed substances such as kratom, 7-hydroxymitragynine, fentanyl analogues, methamphetamines, benzodiazepines, and many others.

From there, a plan should be developed that includes nonopioid medications, nonpharmacologic therapies, regional or neuraxial techniques, and risk-benefit discussions regarding opioids.

In patients with opioid use disorder, if they are receiving medication for opioid use disorder, such as buprenorphine or methadone, these medications should be restarted to prevent withdrawal and cravings. This can also help prevent the need for reinitiation of medication for opioid use disorder, which can be complex, place the patient at risk for returning to substance use, and delay discharge.

Similarly, patients with current or recent opioid exposure often need those medications restarted, with temporary dosage increases to address severe acute pain. Additional evaluation for multimodal pain control with nonpharmacologic therapies and nonopioid analgesics is vital to spare the amount of opioid needed.

Close monitoring of opioid responsiveness and progress toward functional goals should occur throughout the course of treatment. Follow-up pain assessment and expectation setting can help guide additional therapies, deprescribing, and titration or tapering of agents.

Naloxone prescribing should be strongly considered for patients with previous opioid exposure or opioid use disorder.

Pharmacy Times: What role should pharmacists play as patients transition from inpatient or postoperative care to the outpatient setting, particularly in preventing therapeutic duplication, unsafe medication combinations, excessive opioid quantities, and gaps in patient counseling or follow-up?

Kasberg: A key step in the transition of care is to keep in mind the end goal, or “bookend,” for a patient’s pain regimen. For example, if the patient came to the inpatient setting without being prescribed opioids, then the goal will be to eventually taper off opioids within a reasonable timeframe. For certain surgeries, this may be 1 to 3 days, whereas other more severe injuries or larger surgeries may require longer courses of opioids.

Regardless, the patient and the care team should be aware that, eventually, opioids will be reduced and discontinued. If the patient came to the inpatient setting on opioids or medications for opioid use disorder, the pharmacist may be the clinician who collects this information and helps restart these medications in the inpatient setting. These patients may temporarily require higher opioid dosages as acute pain resolves before tapering back to the home dosage.

In either scenario, understanding the patient’s home analgesic regimen can help prevent duplication or unsafe medication combinations during the inpatient stay and at discharge. Early discussion with the patient and care team helps set the stage for eventual opioid tapering and prevents excessive opioid quantities.

Pain pharmacists are also uniquely positioned to counsel patients on medication use and adverse effects and to monitor as-needed use in the inpatient setting.

Pharmacists may also help leverage the electronic health record by creating tools, flags, or pop-ups to ensure thorough clinician review and help prevent duplication, excessive opioid prescribing, or unsafe medication combinations.