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Statement: Managing Pain During the Opioid Crisis

Full Senate Committee on Health, Education, Labor and Pensions

February 12, 2019

ASHP (American Society of Health-System Pharmacists) respectfully submits the following statement for the record to the Senate Committee on Health, Education, Labor and Pensions (HELP) hearing on “Managing Pain During the Opioid Crisis.”

ASHP represents pharmacists who serve as patient care providers in acute and ambulatory settings. The organization’s nearly 50,000 members include pharmacists, student pharmacists, and pharmacy technicians. For more than 75 years, ASHP has been at the forefront of efforts to improve medication use and enhance patient safety.

ASHP’s vision is that medication use will be optimal, safe, and effective for all people all of the time. This includes the safe and appropriate use of medications used to manage pain throughout the continuum of care. Specifically, ASHP’s position on pain management states that we advocate for pharmacist participation in the development and implementation of health-system pain management policies and protocols; support pharmacist participation in pain management through a multidisciplinary, collaborative process that allows for selection of appropriate drug therapies, education of patients, monitoring of patients, and assessment of outcomes of therapy; and advocate that pharmacists lead efforts to prevent inappropriate use of pain therapies.

As the HELP Committee recognizes, a balanced approach is needed to manage pain and address the opioid public health crisis. Inadequate management of acute pain is a patient safety concern, as undertreatment can lead to physiologic stress and can complicate patient recovery and rehabilitation.

Pharmacists are uniquely qualified to provide the type of medication and disease management (including behavioral health conditions) needed to treat pain while addressing the opioid epidemic. Pharmacists offer an in-depth knowledge of medications that is unmatched in the healthcare arena. Pharmacists today earn clinically based Doctor of Pharmacy degrees (Pharm.D.), and many also complete postgraduate residencies and become board certified in a variety of specialties. Pharmacists in hospitals, ambulatory clinics, and emergency departments work with physicians, nurses, and other providers on interprofessional teams to manage patients’ medications and ensure appropriate care transitions.

ASHP engages member experts in the development and dissemination of policies, position statements, case studies, evidence-based guidelines and toolkits, and consensus documents related to pain management practices that minimize opioid overuse or misuse. Our policies and positions emphasize the need for patient-centered care decisions in pain management; leadership over pain management and opioid use within institutions; multidisciplinary, team-based care approaches to optimal pain management and appropriate opioid prescribing; and coordination of care throughout the continuum of healthcare settings. In this statement, we propose four suggestions for managing pain during the opioid crisis.

PAIN STEWARDSHIP

Pain stewardship offers a framework to align and coordinate comprehensive, evidence-based pain management and opioid prescribing strategies. Multidisciplinary members of a pain stewardship team leverage their skills and expertise to establish institutional policies and implement best practices that enable patient-centered pain management and minimize opioid overuse or misuse. Activities coordinated by pain stewardship teams include but are not limited to creation of pain management policies and protocols, identification of multimodal treatment options, academic detailing, and analysis of pain management performance. Pharmacist involvement on pain stewardship teams is essential regarding decisions related to non-opioid and opioid medication selection and modification, patient education, and follow-up and monitoring of medication for patients with acute and chronic pain. In addition, pharmacists provide expertise in managing medication shortages and suggesting alternatives in the context of a pain medication shortage. ASHP recommends the HELP Committee consider payment and regulatory policies that enable and encourage pain stewardship as a standard of practice throughout the continuum of care.

PATIENT RISK ASSESSMENT IN SAFE AND APPROPRIATE PRESCRIBING

Conducting a patient risk assessment prior to initiation of therapies or procedures is a frequently used practice in healthcare to determine optimal courses of action. For example, prior to surgery, risk assessments are employed to identify patients at highest risk for post-operative nausea and vomiting. Once risk is determined, therapy is standardized according to patient need. Therefore, risk assessments are patient-centered and take into account variables such as patient comorbidities, contraindications and allergies, and previous experience. Proactive risk assessments conducted prior to opioid initiation identify patients who are more likely to become opioid dependent and allow for appropriate treatment determination. A unified approach to risk assessment, through research and consensus-building, would be beneficial in advancing this as a standard of practice to identify those more susceptible to becoming opioid dependent.

PATIENT PAIN MANAGEMENT CARE PLANS AND TRANSITIONS OF CARE

ASHP advocates that if opioids or drugs with potential for abuse are included in a patient’s pain management plan of care that it specifically outlines indications of use, goals of therapy, and intended duration of those medications. This promotes patient understanding of the course and expectations of treatment. Patient care plans offer the potential to improve coordination of care between healthcare team members. For example, a care plan developed for a patient transitioning home after being discharged from an acute setting could then be communicated with the community pharmacist. Further, if patient care plans are incorporated into a prescription drug monitoring database, communication between acute care, ambulatory, and community settings becomes efficient and standardized.

TECHNOLOGY AND DATA

Health information systems and machine learning promise great potential in managing care of populations of patients. Healthcare technologies, used appropriately and to their fullest capacity, will positively impact patient care and enhance the efficiency of the prescribing, monitoring, dispensing, and administration of opioids. Clinical decision support systems embedded within electronic health records (EHRs) and programmed with pain management order sets and patient pain management care plans aid prescribers and patients in formulating and implementing care decisions. In addition, EHRs should be interoperable with prescription drug monitoring programs to allow for real-time transmission of data and patient pain management care plans. Data captured through such systems should be continuously monitored by organizations in order to inform future decisions related to patient care and opioid use. For example, population health analysis and academic detailing promote opportunities for improving patient care, advancing clinical knowledge, and conducting continuous improvement activities.

CONCLUSION

Pharmacists are the most accessible patient care providers, working on the frontlines of patient care across the continuum of care to collaborate with and carry out the plan of the initial opioid prescriber. In addition, pharmacists have expertise and experience in managing opioids throughout the medication-use cycle, spanning from medication procurement and storage to patient and prescriber education to dispensing to disposal. We urge you to consider pharmacist involvement in managing pain during the opioid crisis and as a standard of care. ASHP thanks the Senate HELP Committee for holding this important hearing.