Pharmacy-Based Pain Services: Trials and Tribulations of a 10-year Journey

Pharmacy-Based Pain Services Trials and Tribulations of a 10-year Journey Larry Owens, Pharm. D., BCPS Benson Mathew, Pharm. D. Alisha Mutch, Pharm. D. York Hospital, Wellspan Health System York, PA

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Disclosures  Larry Owens: Nothing to disclose  Benson Mathew: Nothing to disclose  Alisha Mutch: Nothing to disclose

Learning Objectives  List services that an inpatient multidisciplinary pain management team can provide  Review useful processes and tools that may be implemented to promote safe and effective patient care  Identify resources available to support the education and training of pain clinicians  Determine the role that pain services can play in the improvement of patient care, medical documentation, education and research

York Hospital – Wellspan Health  South central PA  572-bed community teaching hospital  Seven residency programs  Serving a population of 520,000

Pain Management Team (PMT) at York Hospital – An Evolution 2000

Orthopedic Pain Initiative »Pain team trial

2003

Expansion of service area »Oncology & Palliative Care

2006

Pain Management Team »Full-time position »On-call interventional pain management specialists

Catalysts of Change JCAHO Pain Standards

QA – orthopedic surgery poor patient satisfaction

Pharmacy residency program

Pain Management Committee

“If you build it, he (they) will come” Shortage of pain services Referrals can easily outpace staffing Increasing concern for drug abuse and diversion Do you really want to make this your Field of Dreams?

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Where We Are Now  One clinical pharmacist full-time equivalent (FTE)  Nine clinical pharmacists  Availability: weekdays 7 AM - 3:30 PM  Electronic Medical Record (EMR) documentation  Protocol-based management – majority of consult activity  Service used by wide variety of departments  Palliative Care Interdisciplinary rounds

PMT Consults

1400

Annual Consults

1200 1000 Initial Follow-up Total

800 600 400 200 0 2001

2003

2005

2007

2009

2011

Trials and Tribulations  Workload  Shortage of trained clinicians  Lack of funds for staffing  Defining scope of practice  Protocol development

Strategies for Managing Workload  Restricted hours  Gradual expansion of service area  Limited services – critical care, pediatrics, emergency department  Excluded services – detoxification and neuraxial analgesia  Staff education  Detailed progress notes

Financial Support Evaluation  Fee for service – Low reimbursement – Not available for all patients  Cost justification – Patient satisfaction – Patient safety/risk reduction – Teaching/research contributions  Trial service with existing resources – Shared office space/staff – Residency program opportunities

Pennsylvania Pharmacy Practice Act  Drug therapy management via protocol – Adjustment of medication regimen – Dose, frequency, route of administration, lab and diagnostic testing as necessary  Restricted to the institutional setting  Professional liability insurance requirement  Protocol initiated by licensed physician

The Pennsylvania Code. Available online: http://www.pacode.com/secure/data/049/chapter27/s27.301.html

PMT Referral Process Pain Consult Via EMR

Pharmacist PMT

Recommendations Only

Management Via Protocol

Physician Interventionalist

Contact Established Provider

On-Call Provider List

Pain Management Consult  Reason(s) for pain management consult  Establishes WHO is being consulted – Medication management/pain team – Interventional specialist  Physician determines level of involvement – Recommendations only – Management via protocol – Notes hours of service

Pain Management Protocol  Approved by Pharmacy and Therapeutics and Medical Executive Committees  Initiation/titration of pharmacologic and non-pharmacologic therapies  Opioid route of administration conversion  Adverse effect management  Laboratory or diagnostic testing necessary for the management of drug therapy

Services Provided  Pain assessment and documentation  Opioid risk assessment  Pharmacologic and Non-Pharmacologic Analgesic recommendations/management  Monitoring efficacy and adverse effects  Discharge planning  Coordination of care with outpatient provider  Education

Trials and Tribulations  Quick and efficient response to report of pain  EMR documentation  Inpatient diversion  Risk assessment tool

Tiered Approach To Care PMT & Interventional Specialist Pain Resource Liaison (PRL) Nurse Primary Care Nurse

Developed by the York Hospital Pain Management Committee

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Initial Assessment  Reason for consult  Review of labs, imaging studies, diagnostic tests  Co-morbidities and social history  Medication history  History of present illness  Pain assessment  Adverse effect assessment

Pain Assessment WILDA  Words to describe pain  Intensity  Location  Duration  Aggravating/alleviating factors Goals  Functional goals  Pain intensity Fink R, Pain assessment: the cornerstone of optimal pain management.

BUMC Proceedings 2000;13:236-239.

Pain Assessment

Functional Pain Scale

Functional Pain Score Gloth FM III, Scheve AA, Stober CV, Chow S, Prosser J. The Functional Pain Scale: reliability, validity, and responsiveness in an elderly population. J Am Med Dir Assoc. 2001;2(3):110-114

Opioid Risk Tool Criteria

Score Female

Score Male

Family History Alcohol Abuse

1

3

Family History Illegal Drug Abuse

2

3

Family History Prescription Drug Abuse

4

4

Personal History Alcohol Abuse

3

3

Personal History Illegal Drug Abuse

4

4

Personal History Prescription Drug Abuse

5

5

Age 16-45

1

1

History Preadolescent Sexual Abuse

3

0

Psychiatric Disease (ADHD, OCD, bipolar, schizophrenia)

2

2

Depression

1

1

Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool.

Pain Med. 2005;6(6):432-442.

Opioid Risk Tool  Risk score – Low (0 – 3) – Moderate ( 4 – 7) – High ( =>8)  “High risk patients may receive opioid therapy. Consider the following: increased frequency of office visits, random urine drug testing, reduced prescription quantities, restricted use of PRN opioid and extensive use of analgesic adjuvant.”

Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool.

Pain Med. 2005;6(6):432-442.

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EMR Documentation Automatic consult for patients with: Intrathecal infusions – interrogation and documentation Concentrated PCA therapy

Inpatient Diversion  Vigilance is imperative!  Diversion may occur in many forms: – Fentanyl patch – Oral formulations – PCA pump

 Document aberrant behaviors  Embed sound medication administration practice in nursing policy

Diversion Protocol  Maximize use of non-opioid therapy and non-pharmacologic interventions  Either discontinue or minimize opioid use – Avoid transdermal patch – Avoid IV if possible – Whenever possible, use oral route

 As appropriate, Psychiatry or PMT consult

Trials and Tribulations  PRL training  Reluctance to assume additional responsibility  Cross training staff  Continuing competency and education

Training and Education “I am not a teacher; only a fellow traveler of whom you asked the way. I pointed ahead –” –George Bernard Shaw

Training and Education  Pain Management Apprenticeship – Process – Resources – Precepting model – Competency – Individualization

Training and Education - Process Provide expectations for staff Timeline Provide resources for completion of cases Clinical training: –Inpatient Pharmacist Pain Team –York Hospital Pain Relief Center – Interventional Pain Management –Case review Continuing education

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Training and Education - Resources  Pain treatment algorithms  Standard orders & protocols  Pain management website  Pain management team members  Pain management pocket reference  Wellspan Clinical Effectiveness Team – Chronic Pain

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Training and Education – Precepting Model  Instructing  Modeling  Coaching  Facilitating

Schulthesis NM.”Starring Roles: The Four Preceptor Roles and When To Use Them.” Online CE. 2011. Available: www.ashp.org.

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Training and Education - Competency  Required to practice independently  Written competency –Pain Management – Abbott Northwest Hospital/Aspen –American Society of Health-System Pharmacists - Section of Clinical Specialists

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Training and Education  “Let us never be betrayed into saying we have finished our

education; because that would mean we had stopped growing.” ~ Julia H. Gulliver

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Continuing Education  Requirement

– Three C.E. hours in pain management bi-annually

 Monthly meetings

– Case reviews – Journal clubs – Business meeting

 PAIN WEEK!

– Alternate between individuals – Reimbursement

 Research

Education of Hospital Staff  Bedside teaching

– Elective training – medical/pharmacy residents – Inclusion of nursing staff – Training resource for other regional hospitals

 Presentations

– Grand Rounds – Noon Conference – Resident Research Day – As requested

 Pain Resource Liaison (PRL) Program  Clinical Effectiveness Team (CET)

Value of Research  Means of making changes and measuring outcomes  Way to improve patient care  Provides mean of staff involvement  Provides mean of staff satisfaction

Improvement in Patient Care  Improved patient satisfaction  Promotion of multimodal analgesia  Minimization of side effects  Facilitate timely discharge from hospital  Clear documentation

Patient Comments “The pain team changed my life…”

“The team was very professional and put their heart into my case.”

“I would absolutely recommend this service…I spent the first 16 hours after surgery throwing up and in pain…they quickly righted the situation. Thank you!”

“Miracle workers!”

Awards and Recognition  Wellspan Quality Forum  York Hospital Resident Research  Featured practice in 2006 VHA Research Series – “Evolving Acute Pain Management in American Hospitals: Models and Case Studies”  Pennsylvania Society of Health-System Pharmacists – 2011 Collaborative and Innovative Practice Award

Future Direction  Continue to advocate for patients in pain  Medication profile review for outpatient high-risk opioid clinic  Possibility of staffing outpatient clinic  Cross-training of additional staff  Expansion to 7-day coverage  Coordination of care through transition process.

Summary  Individualized patient care  Think “out of the box” for pain liaisons  Importance of processes to enhance patient safety  Importance of thorough documentation  Value of staff education and research  Availability of resources for staff

References  Fink R, Pain assessment: the cornerstone of optimal pain management. BUMC Proceedings.

2000;13:236-239.  Gloth FM III, Scheve AA, Stober CV, Chow S, Prosser J. The Functional Pain Scale: reliability, validity, and responsiveness in an elderly population. J Am Med Dir Assoc. 2001;2(3):110-114.  The Pennsylvania Code. “Drug Therapy Management.” Chapter 27.301. June 30, 2006. Available online: http://www.pacode.com/secure/data/049/chapter27/s27.301.html. Accessed 6/1/12.  The American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain.

Sixth edition. 2008.  Schulthesis NM.”Starring Roles: The Four Preceptor Roles and When To Use Them.” Online CE. 2011.

Available: www.ashp.org.  Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432-442.