Pain Medications

Community pharmacists are frontline providers in helping patients control and manage acute and chronic pain. They can have a positive impact on identifying and assisting patients who suffer from depression and/or pain. These patients frequently visit multiple physicians for different conditions; yet, they 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 and meaningful interactions with patients can help pharmacists get to know their patients individually and gain a deeper knowledge of their conditions and ailments. This critical knowledge can help pharmacists recommend the proper OTC pain relievers for short-term use and assess the need for more complex chronic pain or antidepressive therapies.

THE CASE

GM is a divorced, overweight, 67-year-old man who is a frequent customer at your pharmacy. He lives alone and is a retired county parks employee with an extensive history of manual labor. You know from previous conversations that he suffers from chronic back pain and periodic mood swings. During your counseling sessions, GM is appreciative and respectful of your time and asks questions. Over the years, GM has had 3 failed back surgeries and has been relatively nonadherent to physical therapy and prescribed medication regimens. Today, GM stops at the pharmacy to pick up his prescriptions for managing his pain and hypertension. This is now the third time you have filled these medications early. You notice GM is not very talkative.

When you ask how he is doing, GM mumbles “OK” while avoiding eye contact. You counsel GM on his medications, remind him that they are being filled early once again, and explain to him the concept behind brown bag and medication therapy management (MTM) sessions. You advise GM that you are actively trying to conduct more comprehensive medication reviews and stress the value behind this service offered by the pharmacy. You tell him that because he suffers from chronic pain and is on multiple medications, you believe he would be an ideal candidate to participate in a brief review. You ask GM if he would be interested in bringing in all of his medications and reviewing them with you for proper use. GM says he is not feeling that great and would be happy to have your attention. He sets up an appointment to meet with you tomorrow when you have some slow time and extra pharmacist coverage.

To prepare for tomorrow’s session, you access GM’s pharmacy profile so you are able to compare it with what is in his “brown bag”:

• Norco 10/325 mg every 4 to 6 hours daily, as needed (filled 1 week early)
• Ibuprofen 600 mg every 6 hours, as needed (filled 2 weeks early)
• Movantik 25 mg every morning
• Sertraline 100 mg once daily
• Cyclobenzaprine 10 mg 3 times daily, as needed
• Lisinopril 20 mg daily
• Hydrochlorothiazide 12.5 mg daily

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

• OTC ibuprofen 200-mg tablets
• OTC multivitamin daily
• 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
• OTC docusate sodium 100 mg

As you review the medications for accuracy, GM tells you about his new onset stomach discomfort and more frequent mood swings. He tells you, in confidence, that his limited budget adversely impacts his ability to follow his physician’s medical advice. He does not go to his doctor as often as he should, frequently self-medicates, and finds help on the Internet and in the pharmacy OTC aisles. You ask GM more questions about his symptoms, and he admits that the medications seem to provide only temporary relief. He has been experiencing many headaches, stomach cramps, bloating, night sweats, and fatigue. GM rates his quality of life as “poor.” He expresses that he just wants relief and comfort so he can enjoy life again.

You and GM briefly discuss his diet and your concerns. GM is taking many OTC medications that he has not disclosed to his provider. Moreover, he has a limited budget and seems to be spending a significant amount of money on his medications. It is noteworthy that GM has not been following up with his primary care doctor regarding his depression and hypertension medications. They have not been titrated in more than 3 years, and he has not had lab work. GM also never followed through on recommendations to visit a cardiologist. You also question the appropriate use of GM’s pain medications. Because of your brown bag session, GM is very interested in participating in the MTM session. You offer to help investigate his issues and concerns.

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