Breaking Down Invisible Barriers

Pharmacists are frontline providers in the fight against depression and pain. Community pharmacists can have a positive impact by identifying and assisting patients suffering from depression and/or pain. Patients frequently visit multiple physicians for different conditions, and yet return to the same pharmacy to fill medications prescribed by a disparate group of physicians. This can present challenges (and opportunities) for community pharmacists. For example, frequent contact and meaningful interactions allow pharmacists to get to know their patients, and their conditions and ailments. This critical knowledge allows pharmacists to recommend proper OTC pain relievers for short-term use and to assess more complex chronic pain or depression therapies.

Unfortunately, many patients are hesitant to ask their provider questions about pain and depression. For some, there is a perceived stigma associated with depression and certain types of pain. Other patients may believe that conditions that can’t be seen will be unduly examined or dismissed. Pain management and depression scales are useful tools. However, generalized or specific pain can be difficult to understand, diagnose, and treat.

Too often, patients with acute pain self-medicate with OTC agents without their prescriber’s recommendation or knowledge. Some patients with chronic pain control episodic pain by adjusting their prescribed medications without their doctor’s knowledge.

This is where pharmacists can make a difference. By being approachable and asking the right questions, community pharmacists play a key role in educating patients with “unseen” ailments. The pharmacy team can improve quality of life by helping patients understand their conditions and emphasizing the importance of proper use of prescription medications. Pharmacists can act as a sounding board for patients who may be more willing to discuss their pain or depression in the pharmacy than at a doctor’s office. Pharmacists can offer alternative treatment options, explain side effects, and optimize treatment and management.

Case: Pain Management and Depression

LB is a 55-year-old female who has been visiting your pharmacy for 3 years. From previous counseling sessions, you know LB works at the local university and visits a number of providers who rotate through the campus health center. LB usually drops off her prescriptions an hour before the pharmacy closes, and she is impatient. You assume she uses multiple pharmacies based on transfer records. LB has a history of chronic back and shoulder pain, migraine headaches, attention-deficit/ hyperactivity disorder, and depression.

When LB comes to collect her medication, you ask if she would be interested in participating in a brown bag session. LB appreciates the opportunity to talk to you and confesses that she “never even thought the pharmacist could help” her. She even apologizes for dropping off her refills “so last minute,” and says she now understands that the pharmacy isn’t a place to “rush through.” You schedule a time to meet with LB.

Upon reviewing LB’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 to 5 days early)
• Escitalopram 20 mg, daily (refill overdue)
• Sumatriptan 100 mg, as directed, as needed (refill overdue)
• Ibuprofen 600 mg every 6 hours, as needed (usually filled 3 to 5 days early)

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

• OTC ibuprofen 200-mg tablets
• OTC multivitamin, daily
• Lisdexamfetamine dimesylate 30 mg, every morning
• Hydrocodone/acetaminophen 5/500, every 4 to 6 hours, daily, as needed (filled at a competing pharmacy 2 weeks ago)
• OTC caffeine pills
• OTC esomeprazole 20 mg

By reviewing LB’s medications, you recognize that LB would benefit from a medication therapy management (MTM) session. You schedule a follow-up appointment with her. An MTM session will allow you to further communicate with LB’s health care providers, obtain lab values, and evaluate LB’s medical goals. In the meantime, you have the following questions and suggestions regarding her medications.

• LB is taking OTC ibuprofen daily, as well as her prescribed pain medications. You suggest she discontinue use of this OTC product. You offer to speak to LB’s providers regarding duplicate therapy and possible lab tests to identify possible toxicosis. Toxicosis may be the reason for LB’s use of OTC esomeprazole, as LB has mentioned that she has been having stomach pain. You counsel her about side effects, and you will follow up.
• You tell LB that you would like to contact her prescribers regarding her pain and headache medications. You question whether they are the best choices for pain and headache control. You ask LB to set goals for your MTM session regarding her pain and headache management issues. You would like to help share her specific concerns with her providers, who may want her to see a specialist.
• LB expresses interest in nonpharmacologic avenues for reducing pain and stress. You review her current diet and exercise regimens and offer advice on local businesses that provide acupuncture, yoga, personal training, and massage.

What else would you suggest to LB?

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, appears on www.PharmacyTimes.com.