Team‐Based Medicine: Incorporating a Clinical Pharmacist into Pain and Opioid Practice Management

Abstract

Background The Centers for Disease Control and Prevention (CDC) reports that death from opioids has increased by more than five times since 1999. In response, federal and state organizations have released guidelines recommending best practice standards to combat the opioid epidemic. Objective To evaluate the impact of a clinical pharmacist in a team‐based care model on the adherence to best practice standards and access to care for management of patients prescribed chronic opioid therapy (COT). Design Retrospective chart review study. Setting An outpatient physical medicine and rehabilitation clinic in a tertiary hospital. Patients Three hundred eighty‐three patients presenting to the clinic between January 2012 and August 2016 with chronic, noncancer pain. Methods Comparison of adherence to best practice standards—including changes in morphine equivalent dose (MED), compliance with urine drug screenings, documentation of medication agreements, initiation of nonopioid medications, and the impact of comorbidities—was analyzed before and after a clinical pharmacist was added to the team. Data were gathered from the electronic medical record and the Prescription Monitoring Program. A control group of patients who did not see the pharmacist and were managed only by the physician section head was also compared to the group of patients managed by a clinical pharmacist. Outcome Measurements The primary outcome measurement evaluates the change in MED values over time. Secondary outcome measurements are to review compliance with annual urine drug screening, documentation of the medication agreement, initiation of nonopioid medications by the pharmacist, and assessment of the access to care for patients with chronic opioid therapy needs. Results A clinically significant reduction in MED with an average decrease of 207 mg was seen after five or more visits with the pharmacist. The pharmacist initiated nonopioid medications at 209 unique patient visits (19.5%). The pharmacist completed 1197 visits during the study time frame, increasing physician access by at least two additional visits per patient per year. Completion of urine drug screens and medication agreement reviews improved over time (P < .001). There was an increase in MED for patients who did not complete this monitoring, whereas the MED remained stable in patients who did complete the monitoring. Conclusions The addition of a clinical pharmacist to an interdisciplinary team managing COT patients resulted in a MED reduction after five or more visits with the pharmacist, improved adherence to best practice standards, optimization of opioid and nonopioid medication therapy, and increased patient access. Developing a role for advanced practitioners, such as clinical pharmacist providers, working with patients on COT can result in significant improvements in patient access to care, adherence to best practice standards, and patient safety. Level of Evidence III.

Impact of Check of Medication Appropriateness (CMA) in optimizing analgesic prescribing: An interrupted time series analysis

“…Besides technology‐based interventions, also ward‐based pharmacy and multi‐disciplinary team‐based interventions can contribute to improved pain management (Boren et al., 2019; Mathew et al., 2016; Poirier et al., 2019; Semerjian et al., 2019). Conversely, many of these interventions are frequently time consuming, less efficient to realize on a hospital‐wide basis and cannot be provided continuously.…”

“…Pharmacy services might be valuable in this regard (Krähenbühl‐Melcher et al., 2007). Studies have already shown that the integration of pharmacists into pain management teams can improve overall pain therapy (Boren et al., 2019; Mathew et al., 2016). For example, Poirier et al showed that a pharmacist‐led pain management service resulted in decreased opioid use (Poirier et al., 2019).…”

Pharmacist‐led intervention on chronic pain management: A systematic review and meta‐analysis

“…Most of the studies were judged to be of average quality. Two of the studies were judged to have a serious risk of bias, 21,26 five moderate, [22][23][24][25]27 and only one low risk of bias. 28 The studies were judged to have a serious risk of bias due to participant selection and confounding (Table S2).…”

“…We also identified five studies where pharmacists were involved in the multidisciplinary or interdisciplinary team for the management of pain. 16,21,[23][24][25] Pharmacists reviewed patient medications, 16 performed opiate stewardship, where they screened and evaluated the use of opioids to support its judicious use, 21,23,24 and provided patient education. 25 These approaches led to improvements in pain score, 16 pain disability index, 24 symptoms of anxiety and depression, [23][24][25] selfefficacy, 25 pain severity and interference, as well as reduced need for morphine use 21,23 (Table 4).…”

“…[23][24][25][26][27][28] Pharmacist intervention or 27,28 Similarly, among five of the reported studies, [23][24][25][26][27] physical functioning was improved in four studies [23][24][25][26] while no impact was observed in the study by Vogler et al in 2017. 27 Pharmacists conducted opiate stewardship and optimized the dose of morphine, with dose reduction in two studies 21,23 and dose increment in a study by Chelminski et al in 2005. 24 Pharmacists identified and resolved medication related problems in two studies.…”