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New Pain Standards Offer Key Role for Pharmacy

Nancy Tarleton Landis

Documenting regular assessment and effective management of patients' pain is all in a day's work for health care professionals at facilities surveyed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). New JCAHO pain standards that took effect January 1 may mean some added time for documentation, but they hold several opportunities for pharmacists, said Rebecca S. Finley, Pharm.D., M.S.

Finley, chair of the department of pharmacy practice and pharmacy administration at the Philadelphia College of Pharmacy, serves on a clinical practice guidelines panel for the American Pain Society, helped formulate cancer pain guidelines for the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research), and has worked on pain management initiatives for the Robert Wood Johnson Foundation. In 2000, she participated in JCAHO-sponsored "pain summits" around the country that were intended to prepare health care practitioners for the new standards.

Areas covered by the standards. The standards were added to various chapters of the accreditation manuals for ambulatory care, behavioral health care, home care, hospice, hospitals, and long-term care. They require organizations to recognize patients' rights to appropriate assessment and management of pain; assess the existence, nature, and intensity of pain in all patients; record the results of pain assessments in a way that facilitates regular reassessment and follow-up; determine and ensure staff competence in pain assessment and management; establish policies and procedures that support appropriate ordering of pain medications; educate patients and their families about effective pain management; and address patient needs for symptom management in discharge planning.

Finley believes pharmacies and pharmacists "are in a great position to take the new standards and run—to look like heroes in implementing these standards in health care systems." Institutions are setting up multidisciplinary committees on pain management, and pharmacists are key players "because they control the drugs—the number one way pain is managed," she said.

Dispensing, formularies, and computer systems. Opportunities for pharmacists to improve the use of drugs in managing pain begin with "the dispensing side," Finley said: ensuring that patients have prompt access to analgesics and that all pharmacy personnel who come in contact with patients have good communication skills and understand the issues for patients with pain. Surveys have found that "patients often feel like they're treated like drug addicts if they have prescriptions for narcotics"—something all pharmacy personnel should be sensitive to, she said.

Furthermore, said Finley, with the new standards, the time is right for pharmacies to examine their formularies "to look at the kinds of patients we take care of, what kinds of pain they have, and whether the products our patients need are on the formulary."

The standards also prompt a new look at computer systems. "Our current systems don't facilitate being able to transfer information from one pharmacist to the next" when the patient moves from one care setting to another, said Finley. "It's emotionally challenging for patients, when they go to a pharmacy with their discharge prescriptions, to have to go through the whole process of justifying their pain to another group of pharmacists."

Pain management competencies. "I think we have made headway in that pharmacists are more knowledgeable about pain syndromes and the appropriate use of analgesics," Finley said. "However, we have a long way to go, and for pharmacists practicing in accredited health care settings, it's a great time to do some competency assessment and identify where the gaps are."

Finley said basic competencies for all practicing pharmacists include communication skills, especially skills in working with difficult patients, such as those who are in pain and have all the associated emotional issues. All pharmacists should also be competent in assessing pain and looking at patient variables; have basic knowledge about analgesics; understand the differences between addiction, dependence, and tolerance; and be able to evaluate the effectiveness of pain management—"know how to get information from patients and interpret what they tell you." Although these things are covered in the curriculum of every pharmacy school, "a lot of people have never had to apply them in practice," said Finley.

Assessment of more advanced competencies, she said, "is where a lot of pharmacies need to think about staff development, mostly in specialized areas like pediatrics or geriatrics, or where specialized routes of administration are used. That's the expertise relatively few pharmacists have, and I believe that lack of expertise accounts for some gaps in the continuity of effective pain management."

Stepping up to the standards. "Some places are much better equipped than others to step right into [the new pain standards]," Finley said. One of those "better" places is the Department of Veterans Affairs (VA). VA pharmacists are active in pain management, said Linda V. Clifford, Pharm.D., a clinical pharmacy specialist at the VA Sierra Nevada Health Care System in Reno, Nevada.

VA health care professionals ask patients about pain at every primary care appointment, treating it as the "fifth vital sign." Pharmacists use computerized progress notes to document pain assessment, said Clifford, who works with oncology patients and is on three hospitalwide interdisciplinary committees related to pain management.

Clifford has a template for cancer pain management in the system and makes notes in it every time she talks with a patient, covering not only her assessment of pain but things like mood, depression, adverse effects, and the patient's spiritual state and possible referral to a chaplain. "We've been addressing pain issues for a long time, and I've always used pain scales," said Clifford. With the JCAHO standards, "people will be doing that more," including more documentation, she said. "We're also doing a lot of education for interdisciplinary staff and patients."

Finley and Clifford agree that interpreting the new standards can be difficult. "You go in and attack certain parts of it and hope you're doing the right thing," said Clifford. The committees at her facility have been busy with this for a year or two, trying to figure out documentation, she said.

Finley noted that pharmacy responsibility is very clear for a few of the standards but that many standards "tell what the outcomes should be and you have to figure out within your institution who does it and how to get it done." For example, she said, patient assessment is often the responsibility of nursing, but the pharmacist may need to assess pain when an outpatient comes to the pharmacy for a refill and does not have a clinic appointment.

Clifford believes the focus of the standards on assessing pain and monitoring treatment for effectiveness is "a good thing" and will bring more pharmacists up to speed on pain management.