Q&A with Larry Owens, PharmD, BCPS, Clinical Pharmacy Specialist, York Hospital, WellSpan Health
Pharmacy Purchasing & Products: What prompted the development of WellSpan Health’s pharmacy-led pain management team?
Larry Owens: The roots of our pharmacist-led pain management initiative were set 18 years ago, when we recognized the need to provide targeted pain management services for patients with orthopedic pain. As a clinical pharmacy specialist, I trialed a pain management service utilizing two pharmacy residents to improve pain management in post-orthopedic surgery patients. The focus was to revise order sets and provide individualized pain management interventions via a pain-management protocol. This was our first experience with clinical pharmacists using a protocol-driven approach to address uncontrolled pain and medication side effect management. At the time, the use of combination opioid/acetaminophen products for the treatment of severe pain was widespread. The goal was to minimize use of these medications and reduce the risk of chronic acetaminophen overdose. This intervention, which was conducted as a resident research project, determined that our efforts significantly improved pain scores and reduced side effects. In addition, a survey of physicians and nurses revealed that the program decreased the amount of time these disciplines spent addressing pain-related issues.
Going forward, I continued to provide consults on a limited basis. Each year the number of consults increased, and I began seeing non-orthopedic patients as well. Eventually, the time commitment required more than a part-time effort by a single individual, so we submitted to administration a proposal for an FTE designated pain-management pharmacist. When this initial request was denied, we focused on the multidisciplinary nature of the program and sought to gain buy-in from administration. Although led by a pharmacist, we emphasized that the team would benefit pharmacy, physicians, nurses, and patients. Some of our strongest advocates were the anesthesiologists, surgical services, and the palliative care team. The following year, the request was accepted.
The FTE is responsible for hospital-wide pain-management consultation, focusing on high-risk patients, as well as serving as an educational resource for hospital staff. The interdisciplinary treatment team at this time included a part-time, outpatient pain clinic nurse practitioner and a clinical pharmacist. However, over time the nurse’s outpatient clinic responsibilities precluded her involvement on the pain team. Consequently, we determined that the team would be led by a clinical pharmacist and began tracking data related to pain-management services, such as the number of patient consults.
PP&P: How has the program evolved since its inception?
Owens: The success of the pain team is contingent on balancing the number of consults with our limited staffing hours. Often, the number of pain consults received by the service can exceed the available resources within an 8-hour day. To manage the time constraint, physicians are asked to refer only their most challenging patients, as opposed to routine cases. Similarly, we aim to limit the number of follow-ups required by the team. For straightforward cases, we provide detailed recommendations within the initial consult, and the referring physician implements these recommendations as they choose to. The team follows the most complex pain management patients closely and directs medication management until they are stable.
For many years, the health system sponsored a 2-day training program for nurses called the Pain Resource Liaison (PRL) Program, which facilitated the development of a specially trained nurse corp throughout the hospital to address the needs of patients experiencing pain. This group serves as a resource to assist with the implementation of standard pain interventions. If patients require specialist care, it is provided in one of two hospital services: the physician interventional specialists (anesthesiologists who specialize in placement of nerve blocks and epidural analgesia), and the pharmacist-led pain-management team. The pain team serves as a representative for outpatient pain practices that do not routinely see inpatients for medication management. The medical staff directs medication management cases from these outpatient pain practices to the pharmacist-led pain-management team, which coordinates care with the outpatient provider.
The pain-management team is staffed by six clinical pharmacists who have received additional training. They rotate onto the team and staff 1 week at a time. Services are provided from 8am until 2pm, Monday through Friday. An early cutoff time is necessary, as a consult can require 90 minutes or more to complete. WellSpan Health requires that consult services occur within 24 hours of the request, unless otherwise informed at the time of the consult. Physicians using the pain-management team consult form are made aware (via the consult form) that consults received after 2pm on a Friday will be seen on the following Monday.
PP&P: What are the elements of the health system’s pain-management protocol?
Owens: WellSpan Health is fortunate that our clinical manager, Robert Patti, JD, PharmD, is also an attorney who helped author Pennsylvania’s Pharmacy Practice Act. We have a collaborative practice agreement in place; I wrote the pain management protocol, which was reviewed by my clinical manager/attorney colleague, and then approved by the P&T committee.
The protocol affords pharmacy significant latitude in caring for patients. When physicians initiate consults, they have the option of simply requesting pharmacy’s recommendations or having pharmacy manage care via the protocol. It is pleasing to note that physicians request that the pain team manage care in over 95% of cases.
The protocol provides a wide variety of pain-management options, including:
- Pharmacologic Interventions: Initiation of opioid analgesics, opioid titration, rotation to an alternate opioid, route of administration changes, use of non-opioid analgesics, and co-analgesics gabapentin, pregabalin, TCAs, and SNRIs
- Nonpharmacologic Interventions: Hot/cold therapy, music relaxation, etc
- Ordering and Monitoring: Ordering lab tests (eg, renal function for patients receiving NSAIDs), EKGs (eg, for patients on methadone therapy), treatments for managing side effects, a naloxone protocol for respiratory depression, an antiemetic protocol to address the frequent side effects of nausea and vomiting, bowel regimens, regimens for opioid-induced pruritus, and anxiolytics and antispasmodics
The WellSpan Health Pain Management Protocol is shown in SIDEBAR 1.
PP&P: What resources and tools are particularly useful for the pain-management team?
Owens: We utilize electronic consult order forms and have developed a number of tools to educate staff, ensure safety, and improve workflow, including:
- Initial Pain Assessment Form. This form is invaluable as it directs the pain team clinician to collect and review all the necessary information for an initial patient consult (see SIDEBAR 2).
- Initial and Follow-Up Consult Documentation. This resource provides clear documentation in the EHR via a template format on many pain-related issues: detailed pain assessment, response to previous treatments, results of prescription drug monitoring screening, and abuse-risk assessment. Follow-up notes are formatted in a physician-friendly manner. Our medical staff requested that the most critical information be addressed at the beginning of these notes, stating either: Continue as ordered or The following changes are recommended. The inclusion of contingency planning if the initial therapy intervention is not successful has proven useful for nighttime and weekend analgesic management.
- Pain Management Card. This resource (see online SIDEBAR 3 at pppmag.com/paincard) is also available as a laminated pocket card. The pain team uses this as a teaching tool for hospital staff. It includes information on pain assessment, non-pharmacologic therapies, analgesic use and dosing, as well as side effect management.
- Implantable Pump Documentation Template. Having a form available online makes it easy for staff to ensure the EHR documentation is thorough.
- Opioid Conversion Chart. From a risk-management perspective, the opioid conversion chart is particularly practical; it was developed in response to reports of individuals within the hospital miscalculating opioid conversions. Staff finds the easy-to-read chart extremely useful (See TABLE 1).
PP&P: How does the pain team balance the competing goals of ensuring access to opioid medications while minimizing the possibility of substance abuse?
Owens: The driving force behind our original pain-management initiative was the 2001 Joint Commission standards for improving care for patients with pain.1 At that time, experts were calling for improved assessments and more aggressive treatment for patients with pain, including opioid use.1,2 The recommendations were based on the available evidence and consensus opinions of experts in the field.3,4 However, in recent years, awareness of the unintended consequences, including adverse events resulting from overly aggressive treatment, has prompted changes to the standards.3-5 The Joint Commission published revised pain assessment and management requirements for accredited hospitals in July 2017.6 The enhanced pain assessment and management standards include the following new requirements6:
- Identify a leader or leadership team that is responsible for pain management and safe opioid prescribing
- Involve patients in developing their treatment plans and setting realistic expectations and measurable goals
- Promote safe opioid use by identifying and monitoring high-risk patients
- Facilitate clinician access to prescription drug monitoring program (PDMP) databases
- Conduct performance-improvement activities focused on pain assessment and management to increase safety and quality for patients
In light of the current prescription opioid crisis, the goal of practitioners is to ensure patients receive appropriate medication to control pain while mitigating unintended consequences and reducing the potential for opioid abuse.
The Joint Commission suggests several evidence-based actions to avoid opioid-associated adverse events, including creating and implementing policies and procedures (P&Ps) for patient monitoring that allow for a second review by a pain-management specialist or pharmacist, tracking and analyzing opioid-related incidents for QI purposes, using IT and automation to monitor opioid use, making appropriate staff and patient education available, and providing standardized tools for screening patients for risk factors associated with oversedation and respiratory depression.7
The Joint Commission’s support for the use of specialized pain-management services, particularly the recommendation for creating P&Ps that allow for a second review by a pain-management specialist or pharmacist, provide support for continuing the pain-management team’s services. High patient and health care worker satisfaction rates also support our efforts to continue our program to provide robust management of opioid medications.
PP&P: What methods are employed to treat patients with substance abuse concerns?
Owens: Our strategy is to maximize the use of multimodal, non-opioid therapy whenever possible. However, we do not automatically avoid opioids in high-risk patients with a valid indication warranting opioid therapy; an embedded statement in the EHR provides built-in recommendations for managing at-risk patients with opioids. If opioids must be used, we utilize a variety of restrictive tactics, including avoiding or limiting IV administration of opioids, using the shortest course of therapy possible, titrating down to the lowest effective dose, limiting the number of dosage units used upon discharge, and avoiding high-risk therapies, such as including multiple sedating medications with long-acting medications (eg, methadone).
When we see patients post-surgery, the pain team can significantly influence their analgesic regimens. With a limited hospital stay, patient education must occur in a timely manner. The pain team’s goal is to gain the patient’s buy-in to multimodal therapy.
It is critical to review and revise order sets used for this patient population. All members of the pain team are heavily involved with developing perioperative order sets, as are anesthesiology and surgery. We make extensive use of oral preoperative or perioperative acetaminophen; IV acetaminophen is used in a very limited capacity. IV acetaminophen is used in a targeted manner due to tremendous cost differences, and is restricted to GI surgical procedures and pediatric patients that are strict NPO. Gabapentin is used extensively in many of our order sets, as are NSAIDs perioperatively, when appropriate.
PP&P: How do the pain team’s services benefit the hospital from a risk-management perspective?
Owens: It is critical to consider the hospital’s liability should an incident occur involving a high-risk patient using opioids. We have found that involvement of the pain-management team, as well as EHR documentation of services rendered, are instrumental in demonstrating that patients have received the highest level of care and that we have advocated for patients to the utmost extent to minimize opioid exposure. In addition, the benefits to the hospital from a risk-management perspective are important discussion points when advocating to administration to maintain or expand pain-management services.
Proper documentation of services is critical to managing risk. The pain team is involved in documenting interventions, and these records are visible to both outpatient and inpatient providers. The initial consult is fully documented, as is the PDMP, which is mandated when opioids are prescribed. Opioid risk assessments are documented on the patient’s chart so they are visible to the prescriber. All adverse events are documented, as are follow-up notes and pain assessments (both from a pain scoring-tool perspective and from a functional assessment). Many routine pain assessments are not evaluated from a functional perspective, but we feel a functional assessment of pain is particularly important. In many patients, pain scores may remain unchanged or change little during a trial of analgesic therapy. When functionality is documented, it provides valuable additional data to make therapy decisions. For example, if pain scores remain unchanged and functionality decreases during a trial of opioid therapy, a strong case is made for the use of alternate therapy.
If a patient enters the hospital with an implantable pain pump, the pain team is mandated by the medical staff to interrogate the pump and document the results of that interrogation in the EHR. In the past, patients with implantable pain pumps have been admitted to the hospital without documentation that a pump was present. Consultant physicians seeing the patient would be unaware that they were prescribing an oral analgesic to someone on high doses of intrathecal morphine. Thus, it is critically important to document the presence of implantable pumps, as well as the pump dose. Pump interrogation and documentation also helps identify the need for a pump refill prior to receiving a low reservoir warning during an extended hospital admission. This provides additional time to plan for acquisition of medication and refill.
PP&P: What patient education is provided by the pain-management team?
Owens: Patient education is a significant part of the pain team’s responsibilities. Discharge planning occurs from the time a patient is admitted. When the pain team first sees a patient, we evaluate approximately how many days we will have to work with them to assign sufficient time for patient education. Education is specific to the patient’s treatment regimen; for example, patients receiving high-risk medications, such as fentanyl patches, are counseled on safe disposal practices and receive written information on appropriate rotation of the patch from one area on the body to another.
PP&P: How satisfied are patients and the medical staff with the pain-management team’s services?
Owens: The medical staff would protest vigorously if we were to reduce or eliminate the pain team’s services. Not only do our services help ensure medication safety and patient satisfaction, but they free up physicians to focus on other patient concerns. The pain team is simply a part of our culture. The pharmacist-led pain-management team has also elevated the role of the pharmacy department within the health system.
Patient satisfaction is a critical consideration. Patients with chronic pain, in particular, often feel mismanaged or overlooked as a result of visiting outpatient prescribers who are not comfortable with pain management or the proper use of opioids and may not be well-versed in the use of multimodal therapy. These patients particularly embrace the role of a pain specialist and the individualized care and interventions that the pain team provides. From a patient safety perspective, having a pain specialist present to provide bedside teaching and rounds presentations is invaluable.
One unique aspect of our service is that the pain team always includes a contingency plan in consults, which is important on nights and weekends when the pain team does not operate. The contingency plan is reviewed with the patient and is referred to if the initial treatment plan is unsatisfactory. Should the patient feel their needs are not being met by Plan A, they can request Plan B. Experience has shown this is highly valued by patients, nursing, and the referring physician, and increases satisfaction. In this manner, the pain management impacts patient care well beyond the hours a clinician is available.
To gauge patient satisfaction, we conducted a survey of pain-management patients from June 2009 through June 2010, and received overwhelmingly positive results for our efforts:
- 86% of patients experienced both chronic and acute pain
- When asked to rate their pain on a scale of 0 (no pain) to 10 (worst possible pain) before and after being seen by the team, the mean pain score before was 8.99 and after was 4.81
- 79% of patients either agreed or strongly agreed with the following statement: After being seen by the pain-management team, I was able to do more (walk to the bathroom, sleep better, participate in physical therapy)
- 80% of patients either agreed or strongly agreed with the following statement: The pain-management team provided education regarding the management of my pain
- 81% of patients either agreed or strongly agreed with the following statement: The pain-management team worked to reduce or prevent side effects from medications
- Several comments on the returned surveys request expansion of the pain-management team service to include outpatient practice
We submitted these results to the Pennsylvania Society of Health-System Pharmacists in 2011 and received the Innovative/Collaborative Practice Award for the state of Pennsylvania.
PP&P: What are the future goals of the pain-management team?
Owens: The pain-management team will continue to advocate for patients experiencing pain and be available for frontline practitioners to assist with the provision of safe and effective pain management. Additionally, we are focused on helping our institution carry out the new Joint Commission standards to improve the care of pain patients.6 Moreover, the opioid crisis amplifies the importance of maximizing the use of non-opioid treatment modalities and has redefined the use of opioids. In the current practice environment the need for a pain-management team is more crucial now than ever before.
- Phillips DM. JCAHO pain management standards are unveiled. Joint Commission on Accreditation of Healthcare Organizations. J Am Med Assoc. 2000;284(4):428-429.
- Max MB. Improving outcomes of analgesic treatment: is education enough? Ann Intern Med. 1990;113(11):885-889.
- Baker DW. The Joint Commission’s Pain Standards: Origins and Evolution. Oakbrook Terrace, IL: The Joint Commission; 2017.
- Baker DW. History of The Joint Commission’s Pain Standards. Lessons for Today’s Prescription Opioid Epidemic. J Am Med Assoc. 2017;317(11):1117-1118.
- Institute for Safe Medication Practices. Pain scales don’t weigh every risk. ISMP Medication Safety Alert, July 24, 2002.
- The Joint Commission Perspectives. Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals. July 2017, Volume 37, Number 7. www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_and_Management_Requirements_for_Accredited_Hospitals1.PDF. Accessed February 8, 2018.
- The Joint Commission Sentinel Event Alert. Safe Use of Opioids in Hospitals. Issue 49, August 8, 2012. www.jointcommission.org/assets/1/18/SEA_49_opioids_8_2_12_final.pdf. Accessed February 9, 2018.
Larry Owens, PharmD, BCPS, is a clinical specialist with the Family Medicine Resident Service and provides supervision/staffing for the Pharmacist-Led Pain Management Team at York Hospital, part of WellSpan Health, in York, Pennsylvania. He received his Bachelor of Pharmacy degree from Virginia Commonwealth University and his PharmD from Idaho State University. Larry has been on staff at WellSpan York Hospital since 1991.
WellSpan Health Pharmacy Pain Management Protocol
Authority is granted to clinical pharmacists to implement the following protocol-based modifications:
- For patients experiencing unsatisfactory pain control or experiencing adverse effects related to the analgesic regimen, the Pain-Management Team may initiate, modify, or discontinue components of the pain regimen as needed. Regimen modifications are permitted as follows:
- Existing orders for opioids may be increased by up to 100% guided by previous response of patient (includes maintenance and PRN doses)
- In the absence of contraindications, analgesic adjuvants/co-analgesics may be initiated. Indications for such therapy and agents include:
- Neuropathic pain: tricyclic antidepressants (TCAs), duloxetine, venlafaxine, gabapentin, pregabalin, carbamazepine, tramadol, tapentadol, topical lidocaine 5% patches, lidocaine topical gel, topical capsaicin
- Acute anxiety associated with acute pain: benzodiazepines
- Muscle spasms associated with acute pain: benzodiazepines, baclofen, cyclobenzaprine, carisoprodol, methocarbamol, tizanidine, metaxalone
- In the absence of contraindications, additional non-opioid adjuvants may be initiated. Indications for such therapy and agents include:
- Mild to moderate pain and/or opioid-sparing effect: acetaminophen, NSAIDs
- Severe pain associated with metastases and/or bone pain: dexamethasone
- Bone pain: calcitonin nasal spray
- Postoperative pain, migraine headaches, fibromyalgia, sickle cell or neuropathic pain: IV/oral magnesium
- Medication orders will follow recommendations for age, renal and hepatic dosing
- Titration of all medications will be guided by clinical response
- Pertinent monitoring parameters, including laboratory or other diagnostic testing, necessary in the management of drug therapy, may be ordered to ensure safe and appropriate use of analgesic medications.
- Non-invasive, non-pharmacological therapies may be ordered to augment pharmacologic agents, including: repositioning, hot/cold treatment, massage, imagery and music distraction, and relaxation techniques.
- Adverse effect management:
- The naloxone protocol may be ordered for all referred patients
- The antiemetic protocol may be ordered for all referred patients
- For the treatment or prevention of opioid-induced pruritis (OIP), antihistamines, ondansetron, and/or low dose nalbuphine/naloxone may be ordered
- In the event a patient demonstrates intolerance to a specific analgesic or co-analgesic medication, therapy may be changed to an alternative analgesic agent. The name of the suspected drug and type of reaction will be documented in the electronic chart.
- In response to patient preference, nausea, vomiting, pruritis, urinary retention, excessive sedation, confusion, or depressed respirations, the Pain-Management Team may discontinue, hold, reduce the dose, or modify medication directions (eg, “hold for excessive sedation”) for all analgesics and adjuvants.
- Use of proton pump inhibitors (pantoprazole) or H2 blockers (famotidine) may be initiated for GI prophylaxis in patients receiving NSAIDS or corticosteroids.
- In the absence of a bowel regimen, laxatives may be ordered or modified for either prevention or treatment of opioid-induced constipation. Agents used for a bowel regimen may include: senna, docusate, bisacodyl, lactulose, sorbitol, polyethylene glycol (Miralax), milk of magnesia, methylnaltrexone, magnesium citrate, sodium phosphate monobasic monohydrate, sodium phosphate dibasic anhydrous (fleet enema), lubiprostone.
- When patients present with adverse effects secondary to opioids or analgesic adjuvants such as recurrent falls, hallucinations, myoclonus, or respiratory depression, de-escalation of opioids or analgesic adjuvant agents to help minimize or resolve adverse effects is warranted.
- Opioid-dependent or opioid-tolerant patients (≥1 week of opioid use):
- Baseline opioid requirements may be calculated and converted to an equipotent dose of opioid
- The PRN dose equivalent may be up to 20% of the total daily dosage
- Doses may be rounded to the closest available dosage strength
- The use of Butrans (transdermal formulation of buprenorphine) may be initiated in patients with moderate to severe chronic pain requiring continuous, around-the-clock opioid analgesia who have unsatisfactory pain control.
- Changes in route of administration:
- Patients permitted to receive oral medications may be converted from an injectable opioid to an equipotent dose of an orally available opioid.
- Patients unable to tolerate oral intake, or if warranted by severe pain, may be converted from an oral opioid to an equipotent dose of an opioid that is available in an alternate route of administration.
Clinical Pharmacology computer database reference
Opioid dose conversion references:
- Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain – 6th ed, American Pain Society.
- Methadone dose conversion reference available on portal under the department of pharmacy’s “Pain Team Resources.”
- McPherson ML. Demystifying Opioid Conversion Calculations: A Guide for Effective Dosing. American Society of Health-System Pharmacists. Bethesda, MD: 2009.
- MS Contin [package insert]. Stamford, CT: Purdue Pharma LP; 2016.
Revised: June 2017 Approved by P&T Committee: July 2017
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