I noticed her the moment she walked into the pharmacy. She was small, at least 20 pounds under her ideal body weight. She had a thick sweater and a furry hat, not only to keep her warm, even though it was in the low 70's, but also to hide her hairless scalp. She had called ahead to make sure we had morphine in stock, letting us know that the chain store pharmacy she normally goes to did not have any and wasn't willing to check with their local sister stores to see if any was available. We are always hesitant when someone calls to ask if we have a specific controlled substance in stock; however, her voice and response to our questions immediately alleviated that concern. We said sure, bring the prescription and we will take a look at it.
Situations like this are not new to us. We are an outpatient pharmacy for the local community hospital. We frequently receive phone calls from patients unable to locate a medication in town or have had a disingenuous experience with one of the local big box pharmacies. We are the end of the line in town and if we are unable to resolve a prescription problem we contact the physician to for an alternative medication rather than return the prescription and dismiss the patient.
This particular patient was new to us so our technician gathered the appropriate information, completed a profile and entered the prescription into the computer. As with any new patient taking a controlled substance we do our due diligence to evaluate the authenticity of the prescription and the appropriateness of therapy. The prescription was written appropriately. Although it was a relatively large quantity of medication it was not unreasonable considering the indication and diagnosis. The prescribing medical oncologist practices out of a clinic less than a mile from our pharmacy and we see this type of prescription from this particular physician regularly.
After a review of our states Prescription Drug Monitoring Program (PDMP) I could find nothing wrong with her prescription. Her pain medication was prescribed by her oncologist and filled regularly at one of two different chain store pharmacies over the past three months. I did notice that she was only receiving short acting narcotic pain medication and no long acting pain therapy. I made a mental note to discuss this with the patient in the counseling session.
The prescription is now filled, paid and signed for and the technician asks the patient to meet the pharmacist over in the counseling area. As I approach the counter I am struck with her overwhelming sense of frustration with the local big box pharmacy system and her incredible feeling of relief that we are able to fill her prescription and also take time to counsel her. She explains that the pharmacy she has been using made her "feel like a drug-addict". She says this as she is taking her furry cap off of her shrinking bald head as if to prove to me that she really is a chemotherapy patient.
For me, this is a breakthrough moment. I appreciate the opportunity to explain to patients that we treat pain as any other disease, just as we treat cholesterol, diabetes and high blood pressure. Of course, we perform due diligence, as stated above, and we do not hesitate to call a physician to discuss the appropriateness of therapy when warranted. Calling patients treated for pain drug addicts is as inappropriate as calling diabetic patients sugar addicts.
After a thorough discussion of this particular medication, I am convinced that she is using her pain medication appropriately and understands its usage. Next, I stated that I noticed she was not using any long acting narcotic medications. She looked at me quizzically, so I went on to explain how patients with extended pain control needs will often be prescribed a long acting medication taken once or twice daily or a patch that is placed every two or three days. The patient will then use the short acting medication for the in between or breakthrough pain.
I like to draw a graph of time (x-axis) versus level of pain control (y-axis). It is easy to show that in this situation, a short acting medication will have multiple spikes over 24 hour, quickly breaking through the pain threshold to a high level, only to fall again within a couple hours down below the pain threshold. These spikes are associated with side effects. In this scenario, a patient needs to plan their day around making sure they always have pain medication with them. They may find that they are limited in their activities and outings due to inadequate pain control and may realize they are constantly looking at the clock to see if it is time for their next dose.
Next, I will draw what a long acting pain medication may look like on the graph. We have a long sloping curve that, over the course of 1-2 hours reaches the pain threshold and continues slightly above the threshold for 8 hours, then falls back below. On the graph it is easy to see that taking the short acting, breakthrough pain medication at strategic times along with a long acting medication may allow for an extended period of comfort with fewer medication related side effects. This process also allows for an increased quality of daily activity time.
Even though the patient had stated that she was satisfied with her pain control regimen, in her three months of chemotherapy related pain control, she had never had this explained to her. She explained to me that with her current therapy, which is liquid and dosed every 3-4 hours, that if she doesn’t wake up in the middle of the night to take a dose of her medication she will be in excruciating agony when she wakes up the next morning. She goes on to explain that even though she takes the medication every 3 to 4 hours, she regularly only gets 1.5 to 2 hours of reasonable pain control and needs to base her daily activities around her medication dosing.
This patient, in her nicest tiny voice, explains to me that her oncologist is fantastic with chemotherapy medication combinations; however he is too busy to understand, let alone explain, her pain management. She actually apologized for her doctor. This got me thinking. In the world of medicine we have many specialties, including pain specialists and medical oncologists. I am certain that if a patient was being treated by a pain specialist and developed cancer that the pain specialist would refer the patient to an oncologist. This is not the case with oncologists. By default, oncologists must also understand pain management.
As stated in a 2011 Journal of Clinical Oncology article, "Limitations in oncologists’ knowledge and practices relating to pain management may be contributing to a substantial unmet need in populations with cancer." The majority of oncologists acknowledge that the quality of the pain management training they received to be only fair. To help remedy this situation “guidelines have been developed and disseminated, pain-related continuing medical education (CME) has become commonplace, and access to pain specialists and specialists in hospice and palliative medicine has increased”. In addition to these factors listed in the referenced Journal of Clinical Oncology article, a complete and through counseling session with a pharmacist is necessary to assure patient understanding and acknowledgement of their pain management and the safe and effective use of pain medications.
To complete the session with this particular chemotherapy patient, I offered to call her physician to discuss the pain medication regimen further. She greatly appreciated the offer; however, she took many notes and stated she would be discussing the issue with her physician within the next couple days. She was very grateful for the information and thanked us for treating her like an individual.
Steve Leuck, Pharm.D., is President/Owner of AudibleRxTM. Dr. Leuck also works full time as a Community Pharmacist in a clinic setting where he practices his counseling on a daily basis.