SHPA's Standard of Practice series is widely utilised and well-referenced by pharmacists and health professionals seeking guidance on the delivery of clinical, operational and specialty hospital pharmacy services. The series draws on the collective expertise of members across all areas of practice and is written by the respective Specialty Practice Leadership Committees.
The following Consumer Practice Standards are available in plain language:
Pain management and pharmacy services
Commonly used terms
- Pain – an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
- Acute pain – normal and time-limited response to trauma or another ‘noxious’ experience, including pain related to medical procedures and acute medical conditions.
- Persistent pain – also known as chronic pain. Long-term pain which persists beyond the normal healing time of approximately three months.
- Hospital pain management – care for patients with all types of pain, including acute or persistent/chronic pain.
- Analgesics – medicines used for reducing pain such as morphine, opioids.
- Analgesic stewardship services – programs which ensure best possible use of analgesics across the health service, by monitoring use and coordinating interventions, with the aim of limiting unintended consequences, including side effects, dependence and cost.
For many hospital patients, pain is both a symptom and a side effect of acute illness and its interventions and treatments.
The International Association for the Study of Pain’s Declaration of Montreal states that access to pain management is a fundamental human right; Australian clinical pharmacy services are essential in delivering effective, efficient, timely and equitable patient-centred pain management.
Pharmacist involvement in hospital-based pain management teams (including pharmacist-led clinics for persistent pain) is proven to deliver the following benefits:
- reduced adverse medicines events
- improved patient satisfaction
- lessened pain intensity
- improved physical function
- reduced use of secondary healthcare resources.
Because patients can present with multiple medical conditions, some of which are frequently associated with pain, the use of analgesics (such as morphine and opioids) is only one element of managing pain.
Pain management services provided by pharmacists
Pharmacists aim to improve patients’ pain management by:
- optimising analgesic selection
- considering possible evidence-based non-medicines treatment options (e.g. physiotherapy)
- limiting unintended consequences (e.g. side effects of medicines, emergence of dependence and cost).
Initial patient treatment
Pharmacists aim to help document the best possible medicines history for all patients as early as possible, preferably before admission. They also support initial treatment and risk management, as well as regularly reviewing treatment plans.
Factors a pharmacist will consider include:
- patient-specific dosing regimens (e.g. medicine choice, dose, frequency of dose and method of administration)
- using combined multiple analgesic medications
- strategies to reduce the risk of analgesic-induced adverse effects (e.g. constipation, cognitive impairment)
- medicines-related risks for reduced mobility, falls, impact on caring responsibilities, and operation of motor vehicles or equipment
- previous opioid use (i.e. has the patient used opioids before; have they had an opioid in the past 90 days and therefore be likely to exhibit opioid tolerance?)
- risks for developing long-term opioid use.
Education and referrals
Pharmacists should be able to provide education to patients and refer them to services which could assist and support self-care for pain management. They should also be able to escalate cases to the coordinator of the patient’s medical care when required as well as facilitate communication between the hospital and primary care provider.
Details which should be communicated regarding analgesia (particularly on discharge) include:
- education regarding the safe and optimal use of analgesics
- a clear plan for pain management, including opioid weaning
- arrangements for medicines review.
Diversion and misuse of analgesics
Pharmacists have a duty of care related to inappropriate prescribing of analgesics. Pharmacists can contribute to identifying and minimising the diversion and misuse of analgesics in the following ways:
- confirming the patient’s medicines history with prescription monitoring services in states where available
- working with pain management units, addiction medicine (e.g. alcohol and other drugs) or mental health colleagues
- facilitating harm minimisation strategies where appropriate.
Responsible use of opioids
Although opioids are important in the management of acute pain, the risks of rising tolerance and dependence rates, as well as community harm, need to be balanced. Pain management pharmacists may promote responsible opioid use by:
- reviewing prescriptions
- advocating for smaller pack sizes
- planning patients’ medicines-use for after they leave hospital
- educating patients about their medicines as well as how to return any unused medicines
- refer to other specialties and healthcare professions where appropriate
- providing education for doctors.
Pain management services provided by pharmacists in varied practice settings
Pain management pharmacists work in varied settings where they are required to respond to pain management referrals or requests.
In the inpatient setting pharmacists may provide services such as:
- reviewing high-risk or complex patients on a medical or surgical ward
- promoting timely de-escalation of analgesics for acute and persistent pain
- supporting discharge planning and transition back to primary care with a pain management plan
- ensuring post-discharge follow-up through either an outpatient clinic pharmacy review, community-provided home medicines review, or an early post-discharge home visit from an outreach transition care pharmacist.
In the outpatient setting pharmacists may provide services such as:
- providing pre-admission clinical services and advice ensuring high-risk patients are reviewed and flagged for increased monitoring and follow-up
- proactively participating in patient case conferences regarding pain management.
- Standard of practice in pain management for pharmacy services (Journal of Pharmacy Practice and Research, June 2019)
- Reducing Opioid-related Harm report – A hospital pharmacy landscape paper (SHPA, November 2018)