Original Research

Pharmacist Pain E-Consults That Result in a Therapy Change

Fed Pract. 2015 July;32(7):14-19

References

1. U.S. Department of Veterans Affairs. Management of opioid therapy for chronic pain. U.S. Department of Veterans Affairs Website. http://www.healthquality.va.gov/guidelines/Pain/cot. Published May 2010. Accessed May 25, 2015.

2. Boyle AM. VA ahead of schedule in improving chronic pain care. U.S. Medicine. 2012. http://www.usmedicine.com/agencies/department-of-veterans-affairs/va-ahead-of-schedule-in-improving -chronic-pain-care. Accessed June 16, 2015.

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4. Roesel T, Engel C. Vitamin D levels and their correlation to pain, fatigue, anxiety, and other co-morbidities in specialized care program service members seen at the Deployment Health Clinical Center. In: Deployment Health Clinical Center Annual Report 2011: pp28-29. http://www.pdhealth.mil/downloads/DHCC_AR_2011.pdf. Accessed May 25, 2015.

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Patients who had a pain e-consult regarding chronic, noncancer pain between January 1, 2012, and March 31, 2012, were identified for inclusion in the study. Charts were selected based on consults submitted by providers. No consults for headaches were requested in the selected time frame.

Chronic pain is defined as persistent pain with or without an identifiable organic cause, lasting longer than 3 to 6 months.¹ Use of the term chronic pain throughout this article refers to chronic, noncancer pain. Criteria for exclusion included patients who received a pain e-consult but died before September 30, 2012.

Data Collection

Patients identified for inclusion had their charts reviewed 6 months after completion of the consult in order to allow sufficient time for potential implementation of recommendations. Patient demographics, name and dose of pain medications, requesting practitioner, type of chronic pain, recommendation of pain e-consult, and consult outcome(s) were recorded for all participants.

The primary outcome of the study was the percentage of recommendations, both pharmacologic and nonpharmacologic, made by the pain specialty pharmacist and accepted and implemented by the consulting provider.

Results

A total of 127 patient charts were identified for inclusion. Five patients died prior to September 30, 2012, and were excluded from the study, leaving 122 charts for review. All 122 charts reviewed by the pain specialty pharmacist included recommendations. Most patients were male (95.1%) and white (75.6%). The most common source of chronic pain was back pain (66.4%) (Table).

Primary Outcome

The pain specialty pharmacist pharmacologic treatment option recommendations varied significantly: add and/or change topical (80% of the 122 patients); add and/or change selective norepinephrine reuptake inhibitor (SNRI) (79%); add and/or change antiepileptic drug (AED) therapy (75%); discontinue opioid (52%); reduce opioid (48%); add and/or change nonsteroidal anti- inflammatory drug (NSAID) (45%); and taper/discontinue benzodiazepine (BZD) (13%) (Figure 1).

Primary care providers could choose to accept or ignore the recommendation, and of all the pharmacologic recommendations made, about 50% were implemented. The rate of PCP implementation of the pharmacist’s recommendations varied: add and/or change AED therapy (54%); add and/or change topical (44%); reduce opioid (42%); discontinue opioid (41%); taper/discontinue BZD (38%); add and/or change SNRI (36%); and add and/or change NSAID (33%).

Despite the most frequent recommendations made by pharmacists, the 3 most accepted and implemented by providers were addition and/or change in AED therapy, addition and/or change in topical therapy, and a decrease in opioid dose. Changes in therapy were identified as either a dose decrease or increase in the existing agent, whereas a new agent was considered an addition to existing pain therapy.

The rates of nonpharmacologic recommendations made by the pharmacist were as follows: ordering additional labs, primarily vitamin D and testosterone levels (55%); referral to physical therapy (PT) (54%); weight loss (51%); smoking cessation (43%); specialty referral (42%); order new urine drug screen (UDS) (35%); referral to pain school education program (26%); transcutaneous electrical nerve stimulation (TENS) (25%); referral to the substance abuse treatment program (SATP) (15%); and update opioid agreement (OA) (9%) (Figure 2).

Nonpharmacologic treatment acceptance rates were as follows: order new UDS (67%); update OA (45%); referral to SATP (33%); referral to PT (33%); order additional labs, primarily vitamin D and testosterone levels (27%); specialty referral (22%); TENS (19%); weight loss (18%); referral to pain school education program (16%); smoking cessation (6%); and music therapy (0%). The top 3 accepted recommendations were obtainment of a new UDS; updating the patient’s OA; and tied for third, referral to PT or the SATP.

Discussion

Including a pharmacist as part of a pain e-consult team may provide support to PCPs for managing chronic pain as well as for measuring improved adherence to VA/DoD guidelines for chronic pain. Pharmacists can offer recommendations for nontraditional pain therapies that PCPs may be unaware of or are unfamiliar with, such as the use of nonnarcotic agents and various nonpharmacologic options. For example, recommend testing for vitamin D levels. Vitamin D deficiency is common among the general population, and a project completed by Roesel and Engel specifically addressed vitamin D deficiency and pain in OEF/OIF veterans.⁴ Other studies have shown a correlation between vitamin D supplementation and a reduction in musculoskeletal pain or the association between low vitamin D levels and hypersensitivity in patients with chronic pain.^5-7Studies have also demonstrated a link between vitamin D deficiency and depression, which is well known to augment or increase patient awareness of somatic reports, like pain.⁸

Of all the pharmacologic recommendations made, about 50% were implemented. It is noteworthy to mention that although a change/ addition in SNRI therapy was recommended by the pharmacist 79% of the time, it was accepted and implemented by the PCP only one-third of the time. Many veterans have co-occurring mental health conditions, which are often managed by a psychiatrist, who is typically not the consulting provider (the PCP is). The PCP may be hesitant to change antidepressant therapy for fear of destabilizing the patient or because the PCP was not the antidepressant therapy prescriber. However, the incidence of co-occurring seizure disorders among veterans is much less than that of mental health disorders, making PCPs much more likely to accept and/or change AEDs. Interestingly, the majority of pain specialty pharmacist e-consults involved chronic pain management, further demonstrating the lack of comfort, time, and/or proper training for PCPs in general pain management.