Pharmacists' Role in the Management of Perioperative Analgesia

More than 75% of patients who undergo surgery experience moderate to severe acute postoperative pain that begins immediately following surgery and may extend beyond hospital discharge.¹ The pain experienced by hospitalized patients can be a significant source of dissatisfaction and slow progression to discharge by blunting patients’ overall functional capacity.² Ineffective pain management during a hospital stay is not uncommon. According to Gupta et al, 32% of patients who completed the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (N = 1898) reported pain as “usually” or “never” well controlled.³ The financial impact of inadequate pain management is estimated to be $635 billion annually.⁴

A variety of barriers to effective pain management have been identified, including inadequate pain assessments, lack of interdisciplinary collaboration, limited time, poor physician—nurse communication, and unrealistic pain goals established by patients.⁵ These challenges may best be mitigated by creating an environment where pain management is a priority, adequate pain assessments are routine, multi-modal therapy is provided, and a treatment plan is designed based on patient history and specific goals. Health care organizations are under pressure to reduce the length of hospital stays while improving patient satisfaction, both of which may be unattainable without the dedicated attention of the health care team to appropriate pain management.⁴

Amid the opioid abuse epidemic, pressures continue to rise for the use of multi-modal regimens to minimize opioid use. Pharmacists’ specialized training in pharmacotherapy makes them uniquely suited to effectively manage a patient’s pain, which often requires a combination of adjuvant therapy and opioids. The ability of the pharmacist to serve as a communication bridge between the patient and health care team can help ensure that patient analgesia is maximized while preventing adverse events (AEs) through appropriate medication selection. Pharmacists collaborate with providers to drive guideline-based treatment. Their role in developing multi-modal pain regimens while mitigating AEs, as well as educating patients about appropriate medication use at discharge, is essential to improving long-term pain-related patient outcomes.

Preoperative Therapy Considerations

Medication reconciliation has long been a pharmacy priority and national focus for health care organizations because of its integral role as a major quality driver of patient care. Forty-nine states can access a state-specific prescription drug monitoring program (PDMP) to help identify patients’ opioid requirements prior to presenting to the operating room.¹ Access to this information positions the pharmacist to guide the health care team in clinical decision making in the perioperative setting.¹ Specifically, use of this tool allows pharmacists to provide guidance to clinicians for appropriate initial opioid requirements while the patient is hospitalized, curbing inappropriate prescribing and reducing diversion. A study conducted by Genord et al evaluated a pharmacist-driven medication reconciliation process in the preoperative setting using the PDMP process, along with patient interviews. Of the orders reviewed, 44% required pharmacist intervention. Furthermore, 86% of the interventions made involved reconciling the correct history of pain medications through the PDMP. Additionally, the authors noted that the pharmacists on the team were often consulted to aid in designing therapeutic regimens for postoperative care.

Pharmacists Optimizing Patient Pain Outcomes

Combining patient history through the PDMP with the pharmacist’s knowledge of pharmacotherapy makes the pharmacist the ideal practitioner for a consultation for perioperative multi-modal therapy recommendations. The American Pain Society guidelines on the management of postoperative pain and the practice guidelines for acute pain management in the perioperative setting support the use of multi-modal analgesia to improve patient pain outcomes.^6,7 Multi-modal therapy includes the administration of 2 or more medications that act through different mechanisms to provide analgesia.⁶ This approach may be achieved through interventional methods, parenteral pain medications, oral analgesics and co-analgesics, transdermal applications, and transmucosal agents. When providing multi-modal analgesia, clinicians and patients must be aware of the AE profiles and appropriate monitoring for each analgesic agent used in order to reduce potential AEs.⁶

Maximizing nonopioid therapy is imperative amid the opioid epidemic but also because of the negative AE profile associated with opioid medications. A recent study conducted by Kessler et al found that 13.6% of patients receiving opioids for postoperative pain experience an opioid-related AE. These AEs were associated with a 55% increase in length of stay, a 47% increase in cost of care, and a 36% increase in risk of readmission. The daily review by pharmacists of patients’ medication administration reports creates an avenue for the pharmacist to collaborate with the health care team to reduce the number of days of intravenous opioid therapy, increase the use of appropriate multi-modal analgesia, and equip the team with a medication discharge plan. Pharmacists’ ability to provide education to providers and patients regarding appropriate pain management, conduct drug monitoring, and prevent and manage AEs make them well positioned to improve patient care.¹

Discharge Preparation and Patient Counseling

In many organizations, pharmacy practice already incorporates discharge counseling to improve patient care and meet the HCAHPS medication communication standards. However, new Joint Commission standards effective in January 2018 will bring a greater focus to opioid-related discharge counseling. The new Joint Commission standards on pain management will require hospitals to educate patients on the pain management plan of care, the AEs of pain medications, and safe use, storage, and disposal of opioids.⁸

In a recent study that evaluated postoperative use of opioids following hospital discharge, the authors found that the prevalence of patients reporting unused opioids ranged between 67% and 92%, with the highest prevalence among the general surgery population. When evaluating the quantity of tablets unused following surgery, remaining amounts ranged from 42% to 71% of what was originally prescribed. Storage was also highlighted as a concern, as up to 77% of patients reported storing medications in an unlocked location. The authors also found that 4% to 30% of patients had plans to dispose of their unused opioids, with less than 10% of these patients describing a disposal method recommended by the FDA.⁹ Pharmacists play an essential role in communicating with patients about medication safety and AEs and may reduce excess opioids being available in the community through appropriate education.

Pharmacists Moving Pain Management Practice Forward

Pharmacists conducting medication reconciliation is an effective approach to establishing a patient’s baseline pain management requirements. Continuing to collaborate with the medical team to reduce days of intravenous opioid therapy, increase the use of multi-modal therapy, and mitigate medication-related AEs will continue to highlight the importance of pharmacists as part of the multi-disciplinary team. Pharmacists providing patient education regarding safe opioid use, storage, and disposal will help to combat the opioid epidemic by reducing the amount of unused opioids in the community. Using these opportunities as a platform to expand pharmacy services will help further enhance pharmacy practice and continue to move the profession forward.

Brittany Johnson, PharmD, is a pain and palliative care stewardship pharmacist at University of Florida Health in Jacksonville.

References

• Genord C, Frost T, Eid D. Opioid exit plan: a pharmacist’s role in managing acute postoperative pain. J Am Assoc (2003). 2017;57(2S):S92-S98. doi: 10.1016/j.japh.2017.01.016.
• Haller G, Agoritsas T, Luthy C, Piquet V, Griesser AC, Perneger T. Collaborative quality improvement to manage pain in acute care hospitals. Pain Med. 2011;12(1):138-147. doi: 10.1111/j.1526-4637.2010.01020.x.
• Schreiber JA, Cantrell D, Moe KA, et al. Improving knowledge, assessment, and attitudes related to pain management: evaluation of an Intervention. Pain Manag Nurs. 2014;15(2):474- 478. doi: 10.1016/j.pmn.2012.12.006.
• Taylor A, Stanbury L. A review of postoperative pain management and the challenges. Curr Anaesth Crit Care. 2009;20(4):188-194. trendsanaesthesiacriticalcare.com/article/S0953- 7112(09)00028-3/fulltext. Accessed?
• Kaasalainen S, Wickson-Griffiths A, Akhtar-Danesh N, et al. The effectiveness of a nurse practitioner-led pain management team in long-term care: a mixed methods study. Int J Nurs Stud. 2016;62:156-167. doi: 10.1016/j.ijnurstu.2016.07.022.
• Chou R, Gordon DB, de-Leon-Casasola OA, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;(17)2:131-157. doi: 10.1016/j.jpain.2015.12.008.
• American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2004;100(6):1573-1581.
• The Joint Commission. Prepublication requirements: standards revisions related to pain assessment and management. The Joint Commission website. jointcommission.org/assets/1/18/HAP_Pain_Jan2018_Prepub.pdf. Published June 19, 2017. Accessed December 11, 2017.
• Bicket MC, Long JJ, Pronovost PJ, Alexander GC, Wu CL. Prescription opioid analgesics commonly unused after surgery a systematic review. JAMA Surg. 2017;152(11):1066-1071. doi: 10.1001/jamasurg.2017.0831.