Brown Bagging Pain Management: Where Does It Hurt?

Patients with chronic pain are prime candidates for a medication review because of possible interactions, toxicities, and adherence issues.

Pharmacists have a positive impact when it comes to identifying and helping patients in pain. Because pain patients frequently visit multiple specialists, pharmacists are often their most consistent health care provider.

Many patients are hesitant to ask their provider questions regarding pain. Pain management scales are useful, but pain remains difficult to diagnose. Often, patients experiencing acute pain use OTC agents without their prescriber’s knowledge. Some patients who suffer from a chronic condition will control pain episodes by adjusting their medications, also without prescriber knowledge.

By being approachable and gaining patients’ trust, the pharmacist can play a key role in educating patients experiencing pain. The pharmacy team can help improve patients’ quality of life by helping them understand more about their specific conditions, treatment options, and side effects.

A brown bag session is an excellent opportunity to provide an unbiased pain management consultation. If more follow-up is needed, a medication therapy management (MTM) session is one way to adequately inform and care for the patient. These simple offerings can help avoid unnecessary medical costs and possibly curb potential pain medication abuse and shortages.

Brown Bag Consult: Chronic Pain Control

AG is a 25-year-old woman who has been coming to your pharmacy for the past 4 years. You know she is a student at the local university and visits a number of providers through the health center on campus. AG always seems to drop off her prescriptions the hour before you close and is impatient if you can’t fill them right away. You assume she uses multiple pharmacies in the area based on transfer records. She has a history of back pain, headaches, attention-deficit/hyperactivity disorder, and depression.

When AG comes to the counter to collect her prescriptions, you ask if she would be interested in participating in a brown bag session. You explain that you are interested in reviewing and reeducating her on her medications. AG appreciates the opportunity to talk with you one-on-one. She confesses that she “never even thought the pharmacist could help her” and thought that you were just there to “count pills.” You schedule a time to meet the next day.

Upon reviewing AG’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)
• Escitalopram 10 mg daily (refill overdue)
• Sumatriptan 100 mg as directed as needed (refill overdue)
• Loestrin Fe daily (refill overdue)
• Triamcinolone cream 1%, apply to affected areas as needed
• Ibuprofen 800 mg every 6 hours as needed (usually filled 3-4 days early)

When AG comes in for her scheduled appointment, the following additional medications are in her brown bag:

• OTC ibuprofen 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, 1/6 refills)
• Tussinex syrup (~60 mL remain, bottle unlabeled, not from your pharmacy)
• OTC caffeine pills

After reviewing the medications in AG’s possession, you schedule a follow-up MTM appointment. An MTM session will allow you to further communicate with all of AG’s health care providers, obtain lab values, and further evaluate AG’s medical goals.

In the meantime, you offer these suggestions regarding her medications:

1. You suggest AG discontinue taking OTC acetaminophen and ibuprofen daily along with her prescribed pain medications. You offer to speak to her providers regarding duplicate therapy and lab tests to identify possible toxicity. This may also be the reason behind her use of OTC omeprazole, as she mentions having new-onset stomach upset. You counsel her about side effects.

2. You suggest to AG that you would like to contact her prescribers regarding her pain and headache medications. You wonder if these are the best choice for pain and headache control. You ask AG to set some goals for your MTM session regarding her back pain and headache management issues. You would like to help share her concerns with her providers, who may want her to see a specialist.

3. AG is noncompliant with her Loestrin Fe and multivitamin. You counsel her on other birth control options and offer to follow up with her provider.

4. AG tells you that the Tussinex prescription was her roommate’s, and she uses it when she needs extra pain control. You counsel her on the dangers of taking others’ prescription medication and dispose of it for her.

What else would you suggest to AG before her MTM session?

Dr. Drury works as a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin. She earned her doctor of pharmacy from Midwestern College of Pharmacy in 2007. In addition to her current work, she is a blogger for PharmacyTimes.com and a speaker for Abbott Pharmaceuticals.