Pharmacy-Led Pain Management in the ED

US Pharm. 2023;48(3):HS8-HS12.

ABSTRACT: Community pharmacists have long been involved in helping people manage their pain, and there is now an increasing presence of clinical pharmacists who serve a similar role in hospital emergency departments (EDs). Given its subjective nature, pain is fundamentally difficult to identify and treat, especially in the ED. Although pharmacists are well poised to contribute therapeutic expertise that would facilitate overcoming this challenge, several barriers to their integration into the ED healthcare team exist. There is a growing body of evidence showing the benefits of pharmacy-led emergency pain management, which will hopefully lead to more emergency medicine clinical pharmacist opportunities.

Over the years, the pharmacist’s role has grown exponentially, encompassing responsibilities well beyond those of merely filling and dispensing medications. Indeed, they have become invaluable and active members of the healthcare team in terms of managing patient health in a clinical setting. One emerging role for the pharmacist is in the treatment of patients in the emergency department (ED).¹ Classified as emergency medicine clinical pharmacists (EMCPs), they work closely with physicians, nurses, and other members of the ED team by providing medication expertise. One arena where these services are especially important is in the management of acute pain, which is particularly challenging in the ED environment.²

Pain is a major reason people go to the ED. Between 2000 and 2010, more than 70% of patients seen in the ED in the United States and Canada complained of pain.³ Common pain-associated medical emergencies include orthopedic injury, migraine headache, gastrointestinal distress, chest discomfort, toothache, and infections (e.g., upper respiratory, skin). Moreover, pain can be difficult to manage in the ED setting for a multitude of reasons. One significant challenge is accurately assessing a patient’s level of pain, which potentially creates a barrier to selecting appropriate drug therapy and achieving patient satisfaction. Often, patients are discharged from the ED with persistent complaints of pain. As medication experts, pharmacists are positioned to supplement the care provided by ED physicians and nurses in order to improve pain management and to prevent adverse outcomes. In fact, pharmacist involvement in ED patient care has yielded positive feedback from patients and healthcare team members alike.⁴ By acquiring a patient medication history and helping to determine the source and extent of the pain, EMCPs can efficiently and methodically identify appropriate treatment regimen in what is typically a chaotic and fast-paced environment. This process becomes especially complex in elderly patients presenting with several comorbidities and taking multiple medications. This article highlights key opportunities where the pharmacist can work within the healthcare team to alleviate acute pain in ED patients.

Role of the Pharmacist in Treating Acute Pain

Pharmacists have long played a role in the treatment of acute pain. In the community pharmacy setting, they routinely recommend and counsel on the use of OTC analgesics with individuals choosing to self-medicate. These products do not require a prescription and are typically medications such as acetaminophen and ibuprofen, which are the more commonly used pain relievers.⁵ When it comes to OTC medication selection, pharmacists often utilize the patient care process, which involves collecting information, assessing, devising a plan, and then counseling the patient on important information (e.g., proper dosing regimen, potential drug interactions, possible side effects) about the product(s) chosen.⁶ Community pharmacists also counsel patients on prescription pain medications such as opioid-based analgesics, which entails the same patient care process, with the exception of medication selection. Key counseling points pertaining to opioid use include avoiding driving, operating powerful equipment, abrupt discontinuation of medication, drinking alcohol, or taking any other medications that could increase the risk of adverse events.⁷ While it is difficult to gauge the full impact that pharmacists have on the management of acute pain in a community pharmacy setting, one meta-analysis reports that pharmacist-led medication review (performed either independently or as part of a multidisciplinary intervention) reduces chronic pain intensity and improves physical functioning and quality of life and patient satisfaction.⁸ Furthermore, pharmacist-led risk assessment of opioid usage in a primary care setting substantially improves provider guideline adherence and opioid prescribing practices.⁹ It therefore stands to reason that pharmacist-led intervention could significantly improve severe, acute pain management in the ED as well.

Challenges to Managing Acute Pain in the ED

Inadequate treatment of pain in the ED is a persistent problem.³ The major types of pain encountered in the ED include acute, chronic, neuropathic, and nociceptive.¹⁰ Orthopedic injuries (e.g., bone fractures, torn muscles, and ligaments), burns, cuts, migraine headaches, and infections are common causes of these types of pain. Pain management in the ED typically entails the administration of parenteral analgesic agents (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs], acetaminophen, opioids, ketamine) and/or application of regional blocks (e.g., Bier block, hematoma block).¹¹ Although pharmacotherapy is a mainstay in pain management, appropriate medication selection can be complicated not only by patient-specific factors (e.g., age, disease state, medication history, pharmacogenetic profile) but also by the chaotic and perhaps overcrowded and discombobulated environment of the ED, where a patient’s analgesic needs might go undertreated or overlooked altogether.¹² Given the subjective nature of pain, assessment of pain and drug selection can be challenging, especially in the ED setting where the amount of time allotted to a patient may be limited. Moreover, some urgent ED interventions (e.g., venipuncture, indwelling stomach or bladder tubes) may even exacerbate a patient’s pain and lead to overall dissatisfaction.¹²

Although opioid-based therapeutics have long been utilized to manage pain, the current opioid crisis has been a major challenge to healthcare providers. The number of opioid prescriptions has declined since its peak in 2011, and they are now usually reserved for short-term use in patients with moderate to severe acute pain.^13,14 Individuals with moderate acute pain are typically initiated on a mild opioid such as tramadol or codeine, whereas those with severe pain are started on a more potent opioid such as low-dose hydrocodone.⁷ The patient is then monitored to determine the effectiveness of the therapy and whether any adjustments should be made. Opioids are seldom considered as first-line agents for chronic pain management, with some exceptions including cancer pain and palliative care.¹³

The potential for opioid-induced constipation and drug abuse is of particular concern when it comes to considering opioid therapy.¹⁴ Renal status should also be considered. Namely, NSAIDs should be avoided in patients with chronic kidney disease. Possible adverse interactions with medications such as benzodiazepines should be identified. Furthermore, certain medications are not recommended in the pediatric and geriatric populations, who comprise a substantive number of ED visits. For example, codeine is contraindicated in children aged 12 years and younger and also in children aged between 12 and 18 years following tonsillectomy and/or adenoidectomy due to the pharmacokinetic profile of codeine in children.^15,16 As medication experts, pharmacists are poised to serve as valuable members of an ED team because they can help manage these situations.

Role Opportunities for EMCPs in the ED

The number of EMCPs has increased over the past decade, which reflects a heightened awareness of their value to the healthcare team.¹ By applying the same patient care process used elsewhere, they can effectively assess complaints of acute pain and recommend an appropriate pharmacotherapy regimen to the physician. Having a dedicated ED pharmacist (vs. soliciting the assistance of an external pharmacist) significantly decreases the time to first analgesia, which optimizes therapy and lowers cost.¹⁷ Moreover, incorporating pharmacists into the ED team leads to reduced medication errors, including those that occur with central nervous system agents used for pain management.^17-19 One of the most fundamental jobs that an ED pharmacist can perform is to acquire a thorough medication history in order to recommend appropriate treatment. This important process (routinely performed in the community setting) allows a pharmacist to determine which, if any, pain treatments have been attempted. Part and parcel to this is the recognition that OTC medications taken at home and that have not effectively alleviated pain are not likely to be effective in the ED.¹² Conversely, OTC approaches that have not been tried at home should be considered first (i.e., pursuing NSAID therapy rather than opioids).¹²

Current Impact of EMCPs in the ED

EMCPs are already having a positive impact in the ED. The benefits include reducing medication errors, enabling direct patient care (e.g., counseling, medication reconciliation), and managing and utilizing resources more efficiently, which is not only bolstering patient satisfaction but also increasing savings.²⁰ Between August 2018 and January 2019, 88 EMCPs at 49 centers made 13,984 interventions, garnering $7,531,862 of cost avoidance in that period.²⁰ Of note, these numbers encompass all of the pharmacists’ duties in the ED and not just pain management. Regarding pain management specifically, EMCPs are improving the postintubation administration of analgesics. One study compared the number of ED patients receiving analgesia as well as the time to initiation of analgesia following intubation without (January 2010 to June 2010) versus with (January 2011 to June 2011) the presence of a pharmacist on the ED healthcare team.²¹ Compared with when the ED did not have a clinical pharmacist on board, the number of patients who received analgesia increased from 20% to 49%, and the average time to initiation of analgesia after intubation dropped by 54%.²¹ The authors also reported on the ability of pharmacists to debunk misinformation about sedative and analgesic pharmacology, namely that sedating drugs also provide analgesia, which could lead to lack of analgesic prescribing.²¹ Despite being a small study, its findings highlight the value of pharmacist-led care in the ED.

Barriers to Pharmacist Presence in the ED

Despite the expanding opportunities for pharmacists in the ED, there are still barriers when it comes to staffing a dedicated pharmacist in this setting.¹ Often, institutions are hesitant to hire dedicated EMCPs because the cost-to-benefit advantage has yet to be determined on a large scale. Also, it is difficult to find pharmacists with formal ED experience, which may be attributable to a lack of dedicated resources for training pharmacists in this area. As of December 2022, a directory search on the American Society of Health-System Pharmacists website revealed that approximately 4% of all accredited/preaccredited U.S. pharmacy programs offer Emergency Medicine Post Graduate Year 2 (PGY2) residency programs.²² Encouragingly, the number of residency opportunities is increasing, as there are currently 98 residency programs compared with only three in 2007.¹ Another barrier to integrating pharmacists into the ED team is negative perceptions that other members might have about it as well as resistance to taking the time and effort necessary to incorporate them into the ED workflow. The financial barrier is most likely the hardest one to overcome, especially for smaller hospitals in rural areas. Initial strategies for overcoming these barriers should be largely centered on the continued formal analyses of the benefits that pharmacist-led emergency care has on acute pain management and patient satisfaction. These analyses might serve to erode apathy about having a pharmacy presence on the ED team and foster increased interest in providing more training opportunities in the emergency medicine setting. Proving the merit of pharmacy-led acute pain management would help to cement EMCPs as indispensable partners in the healthcare team.

Conclusion

As experts in pharmacology and pharmacotherapy, EMCPs are proving to be valuable members of ED healthcare teams. Although pharmacist-led pain management in the ED is rather novel, pharmacists have played a key role in helping people treat their pain since the inception of the profession. It is naïve to think that pharmacist-led pharmacotherapy will solve all of the problems associated with pain management encountered in the ED, but pharmacists are certainly equipped with the knowledge and practical skills to assist in overcoming some of the challenges. Multiple obstacles have hindered a large and dedicated pharmacy presence in the ED. Increased awareness about this growing career path could be achieved, at least in part, through increased advocacy by EMCPs currently serving in the role. Moreover, continued analyses of the positive impacts that pharmacists make to treat acute pain more effectively in the ED would likely grant more legitimacy and expand opportunities moving forward.

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