Q&A: Improving Pain Management Requires Strong Leadership, Robust Data

Pain management in the hospital rarely fails for lack of good intentions; it fails for lack of time, data, and clear ownership.

Physicians juggling packed patient loads often can't give pain control the sustained attention it needs, pharmacists in smaller hospitals frequently lack the bandwidth to weigh in on orders, and many care teams are still working without the tools to see a clear, real-time picture of how opioids are being used across their patient population.

“Unless you have a very specialized pain service, and most organizations may have someone who does that or a group of physicians who manage that, but they’re typically being used for more specialized or more unique cases where patients need really unique or maybe potentially invasive pain control measures like epidurals or nerve blocks,” Richard Dion, PharmD, pharmacy clinical program manager for clinical surveillance and compliance at Wolters Kluwer Health, told Drug Topics®. “Pain services aren’t typically engaged for day-to-day patients who are just receiving maybe oral therapy for pain, but that doesn’t necessarily mean they don’t need that kind of attention.”

Dion has seen these gaps play out across health systems of every size. In part 2 of our discussion, he breaks down what's really standing in the way of consistent, effective pain management, and what leadership, standardized protocols, and better data infrastructure could do to close that gap.

READ MORE: Pharmacists Are Essential Drivers of Opioid Stewardship Programs

Drug Topics: In what ways do factors like inadequate monitoring and communication gaps between pharmacists and physicians hinder effective pain management?

Richard Dion: I think there are gaps in different sections of the care profile or care environment for a patient, particularly in the hospital. I think a big one exists in the gap in which time and attention a clinician, specifically a physician that’s managing a patient in the hospital, has to devote to pain management. Unless you have a very specialized pain service, and most organizations may have someone who does that or a group of physicians who manage that, but they’re typically being used for more specialized or more unique cases where patients need really unique or maybe potentially invasive pain control measures like epidurals or nerve blocks. Pain services aren’t typically engaged for day-to-day patients who are just receiving maybe oral therapy for pain. But that doesn’t necessarily mean they don’t need that kind of attention.

Having a devoted person or group of providers that can offer that sustained guidance around pain control really makes for an effective pain management situation. Then also, utilizing pharmacists in that discussion as often and as early as possible makes for a very complete and comprehensive care package for those patients. So that’s one gap: provider attention and provider availability for that. I specifically speak around physicians and nurse practitioners who could write those orders.

Secondary to that, I do think there’s still a gap in some places for a pharmacist to have a role into that care. In smaller hospitals, critical access hospitals, pharmacists don’t have the time or availability to leave the pharmacy and go up, check on a patient who might need pain control, or talk to them and be involved with the care team when they’re writing those pain orders. Those orders might even be third-tier as far as attention goes. I think that’s also a gap. Trying to engage other clinicians beyond just the ones writing orders really can be helpful too. That’s a big one.

And then another gap is also just lack of data. The Wolters Kluwer Health team has a pretty comprehensive package of software solutions that allows for the identification of real-world and real-time metrics for using opioids, like MME scoring, and identifying patients. But a lot of providers and the care systems they’re using, the electronic medical records (EMRs), don’t offer the tools to allow them to have the data at hand to even make decisions that are helpful. A lot of providers may not have an MME score in front of them, which allows them to understand how potent the patient dosing they’re getting. There may not be a tool to identify patients at risk, given the other medications they’re receiving. I do think that data and the availability of clinical tools that utilize it is really also a gap in this process.

Drug Topics: What are the most prominent challenges among health systems when it comes to the effective management of opioid therapies for treating acute or chronic pain?

Richard Dion: I think there’s a lot. That question could be its own podcast in and of itself, but I do think boiling it down to the most distilled version would be really [that] organizations have to have some level of leadership, attention, and advocacy for pain management programs. If you don’t have someone at the top who can help get resources in place to manage those patients and pain in general, then you’re really not going to ever have an effective program, or it might be piecemeal at best. Having a leadership person who really can go to bat for you as a group will really be helpful in that process.

Also, best practice models are key, and that includes things like order sets and clinical practice guidelines for pain. Make sure that those are integrated into care plans and to the EMR as much as possible to really, for lack of a better word, idiot-proof it. Why give them lots of opportunity to make mistakes or have wide variance between pain control models when we should really just be using a standardized approach as much as possible? If you do need help beyond what standard is available, or if there’s a patient that’s requiring some pretty heavy needs, maybe that’s where you engage a clinical team that is more seasoned or experienced with doing pain control in those situations.

I think that goes back to having leadership commitment too. I do think that stacks. You have someone or a care team that can do pain control rounds or consults, that’s also set up by having a leadership team that allows that to happen. I think those 2 build off each other. That also ties into physician availability. If they’re not available or have the time to dedicate towards that, they’re not going to be available. Engaging models that take not just physicians into account, but also other providers like nurse practitioners, physicians assistants, pharmacists, even pharmacy technicians to help do check-ins or pain scores with patients really can be helpful.

Then the biggest challenge again, going back to what we said before, is about data availability. [It’s] not just real-time data for patients who are admitted to the hospital, but also what do our long-term opioid prescribing practices look like? What’s our duration of therapy? How long are patients receiving those opioids when they’re admitted to the hospital? And then, how much are we giving to them? I think when patients start getting lots of medications in the same class, when they’re going on and off medications, it can be hard to collate that data and really understand what prescribing looks like. That’s also across multiple systems. Patients don’t just engage with one EMR when they’re admitted to the hospital. They oftentimes end up with a system in the ED, another system when they go to the OR, and then they come back to the medical floor. Maybe that’s another situation where there’s disparate data systems. I think having that complete data model is also really helpful.

READ MORE: Pain Management Resource Center