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17 Articles in Volume 20, Issue #3
20/20 with Dr. Suzanne Amato Nesbit: Clinical Pharmacy Roles and Disparities
A Clinician’s Guide to Treating Chronic Overuse Injuries
Adhesive Arachnoiditis: No Longer a Rare Disease
Analgesics of the Future: Cebranopadol as an Opioid Alternative
Ask the PharmD: What role do vitamin D supplements play in treating dysmenorrhea?
Behavioral Pain Medicine: Managing the Affective Components of Pain
Chronic Fatigue Syndrome: Naltrexone as an Alternative Treatment
Chronic Pain and Coronavirus
Connecting the Dots: How Adverse Childhood Experiences Predispose to Chronic Pain
Editorial: Why Are ER Opioids Out of Favor?
Fibromyalgia as a Neuropathic Pain Disorder: The Link to Small Fiber Neuropathy
How the COVID-19 Pandemic Is Transforming Pain Care
Hydroxychloroquine Use and Risk in the Management of Systemic Lupus Erythematosus
Management of Trigeminal Neuralgia in Multiple Sclerosis
Optimizing Care Using a Trauma-Informed Approach
Pediatric Pain Management: A Review of Clinical Diagnosis and Management
The Use of Low Dose Naltrexone in the Management of Chronic Pain

20/20 with Dr. Suzanne Amato Nesbit: Clinical Pharmacy Roles and Disparities

A conversation around the role of physicians and community pharmacists in opioid stabilization, and how the COVID-19 pandemic is revealing clinical disparities.
Pages 65-66
This discussion is part of a new conversation series led by Editors-at-Large Jeff Gudin, MD, and Jeffrey Fudin, PharmD, in honor of PPM’s 20th anniversary of publication. A condensed transcript follows. Access the audio file.
 

Dr. Fudin: Suzanne, we’ve served on a lot of committees together and I am thrilled to have you on this series. Let’s start by looking at your career journey. How did you get involved in pain medicine?

Dr. Nesbit: Well, like many things in life, it was an opportunity. Just a couple of years out of pharmacy school I was asked to teach the medical staff rotating on to the oncology service about pain management and how to manage opiates and care for cancer patients in pain…. My interest grew from there, eventually evolving into a pain management/internal medicine position.

Dr. Gudin: A lot of your work since that time has involved developing and reviewing pain management protocols, which help to shape appropriate practice. What have been some of your major takeaways?

Dr. Nesbit: Well, certainly it’s evolved quite a bit in the last few years in the face of the opioid crisis. I see that in every aspect of patient care, both inpatient and outpatient, not only in terms of how we’re caring for patients, but how we need to educate ourselves as healthcare professionals, taking care of patients, and educating them.

Patients are very fearful of opiates and don’t want to take them, even when they’re clinically indicated. So our whole approach has evolved. We thought opiates were the only tool in our toolbox and that we could use them in perpetuity. What we’re learning is, as with all medications, we need to think about the safe, rational approach to using opiates. More importantly, the opioid crisis has forced us to think about multimodal approaches and to understand that pain is complex, and so our approach to how we deal with pain must also be complex.

Looking ahead, however, we need to be careful in the response to the opioid crisis and balance our approach so that we don’t go back to the days of reserving opioids only for dying patients, which we’re seeing already. We need to keep good solid patient care centered around outcomes and safety parameters.

Dr. Fudin: You were part of the CDC workgroup that explored best practice for opioid prescribing, and you’ve written on post-surgical prescribing of opioids and related topics. What have you found the most surprising in your research?

Dr. Nesbit: There was a dearth of literature and data out there about post-surgical prescribing of opiates. As we started to look at what was appropriate for specific surgical procedures –we initially thought one size fits all, which was clearly not the case. The other aspect, particularly in the CDC opiate estimates workgroup – which was a 6-month engagement looking at prescription claims data – was that it depends on which prescription claims data and what you could glean from it. For example, if you’re looking at claims data you need to make sure it also includes the CMS (Medicaid, Medicare) patient population.

Coupled with that, there wasn’t a lot of literature about the most appropriate pain management for individual procedures. A lot of what we’ve done stems from expert consensus and panels and putting out those recommendations. Now, we need to test those to make sure that they are appropriate and that we’re achieving good outcomes.

The other key issue we uncovered has to do with what our patients were doing with all of those medications we were prescribing….. some weren’t taking them or weren’t disposing of them, they were holding on to them.

Dr. Fudin: Let’s explore this topic more in terms of the importance of opioid stabilization, including reconciliation and what the pharmacist’s role should be from when the patient leaves the hospital, to working with the community pharmacist, and so forth…

Dr. Gudin: From a physician’s standpoint, there’s such sensitivity around opioids. Most states now have adopted a 3-day, 5-day, or 7-day rule for acute prescribing and I see the surgeons in my own institutions who tell patients: ‘Look, here’s your bottle of 30 pills, 40 pills, or 60 pills – do not call me when they run out.’

To Suzanne’s point. I think we’ve gone a little bit too far. There are some patients whose pain is better in 2 or 3 days and they never touch their opioids after that. And there are some patients who start out with chronic pain, who maybe need a little bit more attention for longer periods of time, whether that means opiates or not.

I think the pharmacist clinician has played an incredibly important role. Physicians may see patients for minutes at a time, whereas a pharmacist has typically known these patients for years and understands their comorbidities, their concomitant medications, and can be an important part of the care team when it comes to communicating with the patient and the clinician about what the ongoing needs are.

Dr. Nesbit: I absolutely agree. From a pharmacist’s standpoint, it’s essential that inpatient pharmacists bridge this gap with our community colleagues. Just as patients usually have more than one physician in their healthcare team, we’re entering a period where patients need more than one pharmacist as well. This would be an inpatient or ambulatory based clinical pharmacist that is able to share information and work toward common goals with the patient and the community pharmacists. This is the only way we’re going to achieve medication optimization across the entire healthcare continuum.

As an example, I am on the neuroscience pain resource team at Johns Hopkins, which is a pharmacy and nursing collaborative that talks to post-surgical neuroscience patients. We are helping to manage their inpatient post-op acute pain but also transitioning them to their discharge prescription and discharge regimen for pain.

A lot of this work is about educating the patient on what the discharge regimen entails, whether it’s about opiates, muscle relaxants, acetaminophen, and how all those things work together. We help them understand and optimize their therapeutic analgesic regimen prior to discharge so they have the smoothest transition possible. Otherwise, this is where patient care falls between the cracks – in those intersections or transitions of care.

Dr. Gudin: We’d be remiss if we didn’t talk about COVID-19 and how it’s affecting pain patients who may already have underlying sleep, anxiety, or depression issues, and who have pills on hand at home. How has the landscape changed for you?

Dr. Nesbit: Truly, it’s an evolving answer. Telemedicine has gone from zero to almost 100% in a matter of weeks, which has challenges and opportunities, but what it’s really brought to light very quickly is our disparities. There are patient populations that have been vulnerable before and now that vulnerability is even more glaring because they don’t have the technology or they don’t live in areas that have broadband Internet… and the language services they require become really crucial when you’re in a televisit and trying to get an interpreter on a call. Looking ahead, I think there will be a role for telemedicine; as others have said, it will be difficult to put the genie back in the bottle.

On the inpatient side, we are seeing more patients come in as a consequence of their substance use disorder that can’t get treatment, even if they want to engage. So that is another vulnerable patient population.

We’ve been very focused, for the past few years on opiate stewardship… but now we’re looking at opiate conservation strategies so we can ensure a supply of opiates for those COVID-19 patients who are ventilated and demanding high utilization of opiates. We’re seeing so many different aspects that this pandemic has brought to our practice that no one could envision just mere weeks ago.

Dr. Gudin: As part of this series, we always ask guests what they would say to the young residents and fellows pursuing pain management.

Dr. Nesbit: Pain management is a fascinating field and pharmacists are essential – it’s a great pathway. Make sure you know how to incorporate pharmacogenomics into your practice as I think that’s going to be more imperative in the future. Also, we need to have good clinician pharmacists that are trained not only in pain medicine but in addiction medicine as well. Having an eye to the future for that would be beneficial. 

Suzanne Amato Nesbit, PharmD, FCCP, BCPS, CPE, is on the Palliative Care Service and Neuroscience Pain Resource teams at The Johns Hopkins Hospital in Baltimore. She is a clinical specialist in Pain Management and Palliative Care with the Department of Pharmacy. Dr. Nesbit holds faculty appointments in the Department of Oncology and the Center for Drug Safety and Effectiveness in the Bloomberg School of Public Health at Johns Hopkins, as well as the Schools of Pharmacy at University of Maryland and Notre Dame University of Maryland. She has been practicing in pain management for over 30 years and is a board-certified Pharmacotherapy Specialist and certified Pain Educator. During her tenure at Johns Hopkins, Dr. Nesbit participated in several research protocols and health system pain initiatives, including as co-chair of the Johns Hopkins Hospital Pain Management Committee and as an appointed member of the CDC workgroup on opioid prescribing. She is immediate past president of the American Society of Health-System Pharmacists.

 

Throughout 2020, we will be featuring more dialogues on the evolution of pain management over the past two decades and what the future may hold. To get involved, email the editorial team. See Episode 1 with Lynn Webster, MD and Episode 2 with Peter Staats, MD, Episode 4 with Nathaniel Katz, MDand Episode 5 with Drs. Carmen R.Green and Johnathan Goree and Mark Wallace, MD.
 
 
Last updated on: November 16, 2020
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20/20 with Peter Staats, MD: The Future of Pain Medicine
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