Original Research

Pharmacist Pain E-Consults That Result in a Therapy Change

Pain specialty pharmacists can provide support to prescribing primary care providers and enable changes in therapy.

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

Author(s):

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.

3. Sproul RD. Bridging the gap: e-consult pain service for the primary care physician. Am Soc Pain Educ. 2012;8(1).

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.

5. Le Goaziou MF, Kellou N, Flori M, et al. Vitamin D supplementation for diffuse musculoskeletal pain: results of a before-and-after study. Eur J Gen Pract. 2014;20(1):3-9.

6. Abbasi M, Hashemipour S, Hajmanuchehri F, Kazemifar AM. Is vitamin D deficiency associated with non specific musculoskeletal pain? Glob J Health Sci. 2012;11;5(1):107-111.

7. Von Känel R, Müller-Hartmannsgruber V, Kokinogenis G, Egloff N. Vitamin D and central hypersensitivity in patients with chronic pain. Pain Med. 2014;15(9):1609-1618.

8. Anglin RE, Samaan Z, Walter SD, McDonald SD. Vitamin D deficiency and depression in adults: systematic review and meta-analysis. Br J Psychiatry. 2013;202:100-107.

9. McAdams M, Cannavo L, Orlander JD. A medical specialty e-consult program in a VA healthcare system. Fed Pract. 2014;31(5):26-31.

10. Fan T, Elgourt T. Pain management pharmacy service in a community hospital. Am J Health Syst Pharm. 2008;65(16):1560-1565.

11. Andrews LB, Bridgeman MB, Dalal KS, et al. Implementation of pharmacist-driven pain management consultation service for hospitalised adults with a history of substance abuse. Int J Clin Pract. 2013;67(12):1342-1349.

12. Hadi M, Alldred D, Briggs M, Munyombwe T, Closs SJ. Effectiveness of pharmacist-led medication review in chronic pain management: systematic review and meta-analysis. Clin J Pain. 2014;30(11):1006-1014.

13. Briggs M, Closs SJ, Marczewski K, Barratt J. A feasibility study of a combined nurse/pharmacist-led chronic pain clinic in primary care. Qual Prim Care. 2008;16(2):91-94.

The enormity of chronic pain among the veteran population makes pain management within the VA a critical issue. Of the veterans returning from Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF), chronic pain is the most common report.¹ Of equal concern is the lack of available pain specialists in the U.S. There are < 4,000 pain specialists in the U.S., and even fewer pain specialists are available within the VA system, making it difficult for veterans to access pain care and timely treatment.²

Furthermore, one of the biggest challenges surrounding pain management is the lack of proper training received by generalists and primary care providers (PCPs). Whereas opioid therapy was previously prescribed mainly by specialists and mainly to cancer patients, that is no longer the case. Today, nonspecialists frequently prescribe opioids, and 95% of long-acting opioids are for chronic, noncancer pain.¹ In a majority of reviewed pain electronic consultations (e-consults) completed by the pain specialty pharmacist at the Bay Pines VA Healthcare System (BPVAHCS), the patient was not currently receiving opioid therapy, suggesting PCPs’ lack of comfort and training in chronic pain management. Effective and appropriate pain management from the patient perspective and confidence and reassurance from the prescriber standpoint cannot be successfully achieved without drastic improvements in education and training.

The inception of the E-Consult Pain Service arose from a grant from VA National Innovations in Consult Management to 3 VA facilities in Florida: BPVAHCS; Orlando VAMC, and North Florida/South Georgia Veterans Health Systems.³ At the Orlando VAMC, PCPs needed advice on pain management for patients while they waited to see a pain clinic specialist, so a Pain Help Line was implemented to provide immediate consults, but miscommunication between recommendations given and their implementation limited its utility. That eventually led to an E-Consult Pain Service, which provided formal full chart reviews for pain management cases.

The E-Consult Pain Service program included 2 full-time pharmacists, a part-time pain psychologist, and a pain physician. Its goal was to assist PCPs with patient-specific pain management recommendations. The consult service did not replace specialty pain clinics, nor was it meant to provide continual pain management. Additional, separate pain e-consults could be scheduled as a follow-up to a previous consult or for new pain management issues. Although the recommendations in the consults were available for the provider’s use, it was at the provider’s discretion as to whether the recommendations were accepted and implemented.

The E-Consult Pain Service

The E-Consult Pain Service at the BPVAHCS started July 2011. Staffed by a full-time physician and pain specialty pharmacist, the program provides electronic chart review and recommendations to PCPs regarding complex pain management issues. About three-fourths of their time was spent directly on the consults, which took between 1 and 5 business days to complete. Their remaining time was spent on educational initiatives and administrative duties.

The BPVAHCS is a complexity level 1a facility providing comprehensive health care. The facility comprises a 192-acute care bed hospital (includes intensive care, medical, surgical, and psychiatric units); a 112-bed community living center; a 65-bed domiciliary; and a 34-bed residential treatment program.

Initially, the program was developed to provide pain management support to PCPs in the community-based outpatient clinics (CBOCs) but expanded to all BPVAHCS providers. With the expansion, the program helped reduce a 3-month delay for patients waiting to be seen in the pain clinic. Goals of the program included improving patient outcomes and safety while minimizing opioid therapy risks. These goals are met through an individual case consultation as well as formal educational programs for providers.

The purpose of this study was to obtain data evaluating the characteristics of recommendations made by a pharmacist through pain e-consults at the BPVAHCS and the percentage of consults that resulted in a change in therapy. Future research is warranted to provide clarity on why specific recommendations are or are not being accepted, patient outcomes, and PCPs’ perception on the program’s utility.

Methods

An institutional review board-exempt, retrospective chart review was conducted at the BPVAHCS to determine the percentage of patients whose pain regimen changed as a result of a pain e-consult completed by a pain specialty pharmacist. Although the BPVAHCS E-Consult Pain Service comprised a physician and a pain specialty pharmacist, this study was focused solely on the role and recommendations by the pharmacist. The characteristics of those recommendations and their acceptance/rejection rate were then recorded. Of note, the physician completed separate e-consults, and the frequency of input by the physician on pharmacist recommendations was not collected.