Clinical oncology pharmacists evaluate and treat pain through pain management consultations at Porter Cancer Care Center. As part of the comprehensive cancer treatment program at Porter Adventist Hospital in Denver, Colorado, Robin Mower, PharmD, and colleagues provide one-on-one pain evaluation consults to enhance the quality of life of patients with cancer. Fortunately, Colorado allows collaborative drug therapy management (CDTM) between physicians and pharmacists, allowing the clinical pharmacists at Porter Adventist Hospital to provide pain management under the CDTM protocol. In addition to inpatient oncology pain management consults, the clinical pharmacists provide pain management for outpatients in radiation oncology and the outpatient medical oncology clinics. Furthermore,pain consults at Porter Adventist Hos - pital are not limited to oncology; the clinical pharmacists also help any hospital inpatient who suffers from acute and/or chronic pain.
Located on the oncology floor, the program grew out of a need to focus on this aspect of cancer care. By having pharmacists involved in the management of pain, the program uses their specialized medication knowledge to optimize treatment. Mem bers of the cancer care team have found that this service helps them with time management, allowing physicians and nurses to focus on other aspects of their patients’ care.
How It Works
“The physicians can write for a ‘pharmacist pain consult,’ and the clinical pharmacists provide pain management services. Under CDTM protocols, the physicians allow us to write orders for pain medications in addition to pain medication side-effect management, such as bowel regimens for treatment of opioid-induced constipation,” Mower tells The Oncology Pharmacist. “We meet with the patients to assess and evaluate their pain. We check to see where the pain is located, what type of pain it is, how the patients rate the pain, what makes it better, what makes it worse, and what have they tried in the past. We also discuss what the patients’ pain goals are and work on realistic goals together. We decide what medications might be best based on their history and comorbid conditions, and are able to write an order for the pain medications.”
Follow-up is very important. Mower sees patients regularly to ensure their pain is controlled. “For example, in the radiation oncology clinic, many pa - tients visit every day and I can therefore meet with them every couple of days face-to-face; occasionally it might be a phone contact,” she illustrates. “The nurses play a crucial role in identifying patients that may need a pain consult by the pharmacist. We work closely together. If they feel like a patient isn’t getting his or her pain controlled, they will talk to the physicians and suggest they get a clinical pharmacist involved. I would say that we have a close working relationship with the physicians and that 99% of the time they take the recommendation and an order for a pain consult begins.”
For pain management issues that are not amenable to treatment by medications alone, Porter Cancer Care Center has a palliative care team to which the pharmacists can refer a patient. This team comprises a medical director, an advanced practice nurse, a case manager, a social worker, and a chaplain, and it has access to anesthesiologists and psychiatrists.
Patient-Focused Care
Ten years ago, when Mower began at Porter Adventist Hospital, there were no pain management consults. Pain was treated by the physicians, along with all of the other aspects of cancer care. “When I came here, the nurses were asking, ‘I am giving quite a bit of hydromorphone to this patient, what can we do differently?’ or ‘This pain is not controlled well, what can we do?’” To Mower, the solution seemed clear: She should offer her services for pain consultations. With her residency in hematology/ oncology and her focus on pain management during undergraduate study and doctoral training, Mower did just that.
From there, the program grew, now encompassing not only oncology inpatients and outpatients but also inpatients from all units of the hospital. Mower trained the hospital’s other clinical pharmacists to provide the service as well, so all patients in need can have help with their pain.
With this success, Mower has been able to focus all of her time on clinical pharmacy, with other pharmacists in the main hospital pharmacy performing order entry. “My office is on the oncology floor in the inpatient unit. For the outpatients, it is a short walk to the outpatient clinic and I can provide services there,” she explains. “Since my office is located on the inpatient nursing unit, it enhances the care patients receive in that I am readily available for questions by nurses or physicians. In addition, we have multidisciplinary rounds which help identify patients who may benefit from a pharmacist pain consult.”
Future Goals
With all of their success, one goal still eludes the pharmacists offering pain management—reimbursement for their services. “Right now, our services are free,” Mower notes. Given the improved pain relief experienced by the patients and the cost-savings associated with such tailored drug therapy, she is working on it. “That is something I am looking into; I haven’t had success just yet.” She is exploring the possibility of setting up a true clinic similar to the hospital’s anticoagulation clinic, which might allow the pharmacists to bill for their services in pain management.
The oncology pharmacists are rewarded in other ways. “The physicians seem satisfied with the service. They don’t have to worry about pain management so they can focus on something else. The patients seem satisfied because they have somebody focusing on the pain, which is one of the biggest complaints of oncology patients, and for that matter all patients. Knowing that I have personally helped relieve one of the most traumatic symptoms of a disease is reward in itself.”
