Pain Management: Aisle 4

Pharmacists can have a positive impact by identifying and helping patients in pain. Knowing patients and their ailments is essential when recommending OTC pain relievers for short-term use or when assessing complex chronic pain-management therapy.

Many patients are hesitant to ask their provider questions regarding pain-related issues, as pain is something you “cannot see.” Pain-management scales are useful tools, but this health concern remains difficult to properly diagnose. Often, patients who are experiencing acute pain elect to self-medicate with OTC agents without professional recommendation or adequate knowledge. Some patients who suffer from painful, chronic conditions will control their episodes by adjusting their prescribed medications without provider knowledge or by self-treating undesirable adverse effects (AEs) from pain medications.

By being approachable and acting as a cornerstone of trust within the community, the pharmacist can play a key role in educating patients suffering from any type of pain. The pharmacy team can help improve patient quality of life by helping patients understand more about their specific condition, treatment options, AEs, and optimal medical management.

Incorporating Professional Pain Management

EA is a 55-year-old man who has been visiting your pharmacy over the past several years to have prescriptions filled. You know from past counseling sessions that he is an office manager for a local downtown company. EA seems to always drop off his prescriptions 1 hour before you close and can be impatient. Based on transfer records, you understand he uses multiple pharmacies in the surrounding area. He has a history of back pain, headaches, arthritis, and depression. You review EA’s profile and note your concerns about adherence.

When EA comes to the counter to collect his prescriptions, you ask if he would be interested in participating in a brown bag session. You explain what happens during a brown bag consult and tell EA you are interested in reviewing his medications with him. EA appreciates the opportunity to talk with you in depth, one on one. He confesses that he “never even thought the pharmacist could help him” and that he thought we were just there to “count pills.” He even apologizes for dropping off his refills “so last minute” and now understands why the pharmacy is not a place to “rush.” You schedule a time to meet again the next day.

Upon reviewing EA’s current medication profile at your pharmacy, you find the following:

• Norco 10/325 mg every 4 to 6 hours daily as needed (usually filled 3-4 days early)
• Sertraline 100 mg daily (refill overdue)
• Sumatriptan 100 mg as directed as needed (refill overdue)
• Hydrocortisone cream 2.5% to apply to affected areas as needed
• Ibuprofen 800 mg every 12 hours as needed (usually filled 3-4 days early)
• Alprazolam 0.5 mg every 12 hours as needed

When EA comes in for his scheduled appointment, you notice the following additional medications in his brown bag:

• OTC brand Advil 200-mg tablets
• OTC acetaminophen 500-mg tablets
• OTC omeprazole 20-mg capsules
• OTC multivitamin daily
• Hydrocodone/Acetaminophen 5/500 every 4 to 6 hours daily as needed (filled at competitor pharmacy 2 weeks ago)
• Tussionex syrup (~60 mL remain, bottle unlabeled, not from your pharmacy)
• OTC caffeine pills
• OTC calcium carbonate chews

After reviewing EA’s medications, you realize he might benefit from a medication- therapy management (MTM) session and you schedule a follow-up appointment. An MTM session will allow you to further communicate with all of EA’s health care providers, obtain lab values, and further evaluate EA’s medical goals. In the meantime, you have some questions and suggestions surrounding his medications:

• EA is taking OTC acetaminophen and ibuprofen daily along with his prescribed pain medications. You suggest he discontinue use of these products and offer to speak to his providers regarding duplicate therapy and possible lab tests to identify any resulting toxicity. This may also be the reason behind EA’s use of OTC omeprazole and calcium carbonate for his upset stomach. You counsel him on AEs and will follow up.
• You suggest to EA that you would like to contact his prescribers regarding his pain and headache medications because you wonder if these are the best choices for back pain and headache control. You ask EA to set some goals for your MTM session regarding his pain management issues. You would like to share his concerns with his providers, who may want him to see a specialist, and you also review exercise goals, as EA mentions his sedentary lifestyle at home and work.
• EA tells you the Tussionex prescription was his wife’s prescription but he keeps it around for when he needs extra pain control. He states that it seems to work quickly and tastes good. You counsel him on the dangers and dispose of the medication for him.

Dr. Drury works as a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin. She earned her doctor of pharmacy from Midwestern University College of Pharmacy. Her blog, Compounding in the Kitchen, an innovative amalgam of pharmacy and cooking, appears on www.PharmacyTimes .com/blogs/compounding-in-the-kitchen. Read, and enjoy!