Laura Murphy, BScPhm, ACPR, PharmD
Karen Ng, BScPhm, ACPR, PharmD
Clinical Pharmacists
Altum Health
University Health Network
Toronto, Ontario
Chronic noncancer pain is a significant problem in modern society, and its negative effects on quality of life and productivity result in immense social and economic impact.1 To aid clinicians in the management of chronic noncancer pain and to address related challenges in managing opioid therapy, the National Opioid Use Guideline Group published the most recent version of the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain in 2010.1 The guideline highlights the challenge of balancing effective treatment of chronic pain and prevention of harm, emphasizing that client care is improved if clinicians collaborate across disciplines. These core concepts form the foundation for clinical pharmacist services in support of better client care at Altum Health, an ambulatory clinic within the University Health Network in Toronto, Ontario..
Altum Health provides innovative care for injured workers through specialty programs created to provide comprehensive care for these clients. These programs are covered through third-party insurers, including Ontario’s Workplace Safety and Insurance Board. Altum Health is recognized nationally as a leading provider of rehabilitation programs and services. These specialty programs address a variety of physical, psychosocial, and behavioural issues related to injury, including chronic pain. Collaborative services offered by physiotherapists, occupational therapists, kinesiologists, cognitive–behavioural therapists, psychologists, physicians, psychiatrists, and return-to-work coordinators involve treatment goals for clients that range from prevention and management of acute and chronic injury to integration back into the workplace and home life.
In 2009 Altum Health, formerly known as Rehabilitation Solutions, recognized a need to add clinical pharmacists to its team of health care professionals. Patricia Marr, a pharmacotherapy specialist with University Health Network, was initially seconded to pilot the role of a clinical pharmacist in this specialty clinic. It was clear from Dr Marr’s involvement that a clinical pharmacist could make valuable contributions to the team. There was also increasing demand for medication management for the clients at Altum Health, specifically management of opioid medications, with the Workplace Safety and Insurance Board rolling out its current Narcotic Strategy2 and the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain 1 being published. Laura Murphy and Karen Ng started as full-time clinical pharmacists with Altum Health in October 2010, in positions contracted through the Department of Pharmacy of University Health Network. Their positions include responsibilities for clinical practice, development and evaluation of programs, education, and outcome-based research. In less than a year, these clinical pharmacists have been integrated into teams within existing Altum Health programs, and they are also part of new programs, including the collaborative Substance Management Program with the Centre for Addiction and Mental Health, which began in April 2011.
The clinical pharmacists’ responsibilities include participating in collaborative, interprofessional assessments of clients and providing consultative services during treatment programs. Their contributions to client assessments include pharmacotherapy workups to identify drug therapy problems, and their treatment consultations involve the creation and implementation of pharmaceutical care plans with appropriate monitoring. Clients are referred by the treatment team to receive pharmacist consultations as needed, including education about medications, management of medication coverage issues, and communication with community prescribers to facilitate seamless transfer of care after program completion. Assessments and treatment consultations focus on optimizing drug therapy to manage pain, depression, anxiety, insomnia, and substance dependence; however, the complete picture of clients’ past and current drug therapy is reviewed to ensure appropriate selection of drug therapy and to check for interactions.
Clients with chronic pain and chronic pain disorder who are referred to Altum Health for medication management services typically have complex medication issues. Common drug therapy problems identified in these clients involve excessive dosing of over-the-counter pain medications, excessive dosing of opioid therapy, aberrant opioid-related behaviours, requirement for treatment for substance dependence or abuse, ineffectiveness of pain medication (which may have led to behaviours of pseudoaddiction), suboptimal dosing of neuropathic pain medications, inappropriate use of benzodiazepines, untreated indications for antidepressants, and inappropriate sleep therapy. Care plans often involve individualized tapering schedules and monitoring recommendations for opioids and benzodiazepines.
Collaboration between the clinical pharmacists and other health care providers at Altum Health is essential for the provision of medication management to this challenging client population. All members of the team flag medication issues and contribute to medication monitoring, but unique collaborations with subsets of team members have been developed to address more specific client issues. Some examples include medication assessments involving a clinical pharmacist and either a physician or a psychiatrist, medication adherence teaching involving a clinical pharmacist and a cognitive–behavioural therapist, and management of mood or substance dependence involving a clinical pharmacist, a psychologist, and a cognitive–behavioural therapist. Occupational questions relating to medication use and driving or operation of machinery, which are unique to clients of the Workplace Safety and Insurance Board, require collaborative input of a return-to-work coordinator, an occupational therapist, a physician, and a clinical pharmacist.
Documentation of clinical pharmacist services at Altum Health must meet high standards and requires consideration of medicolegal obligations. Reports must clearly communicate to third-party payers the findings of an assessment or the client’s progress during treatment. These reports are also sent to the client’s community physician and must therefore effectively inform health care professionals along the continuum of care.
Clinical pharmacy services are expanding rapidly at Altum Health, and ongoing program development and evaluation represent another important part of the pharmacists’ roles. This has included continued development of best practice guidance for calculation of morphine equivalencies, recommendations for use of new drug products and formulations, and triage criteria for the services of a clinical pharmacist. Future endeavours are planned to incorporate outcome-based research for quality assurance and to address issues identified as potentially improving medication management for clients with chronic pain. Involvement of Altum Health as a practice site for rotations in the undergraduate and graduate pharmacy programs at the University of Toronto, as well as the Ambulatory Residency Program, is planned to begin in 2011.
Many clients with chronic noncancer pain are at high risk for drug therapy problems and can benefit from pharmacists’ services as part of interprofessional management. The need for clinical pharmacists is expected to increase both at Altum Health and in similar clinics managing the care of clients with chronic pain.
1. Canadian guideline for safe and effective use of opioids for chronic non-cancer pain. Version 4.5. National Opioid Use Guideline Group; 2010 [cited 2011 Apr 8]. Available from: http://nationalpaincentre.mcmaster.ca/opioid/
2. Enhanced narcotic management for injured workers, WSIB narcotic strategy. Toronto (ON): Workplace Safety and Insurance Board; [cited 2011 Apr 8]. Available from: www.wsib.on.ca/en/community/WSIB/230/ArticleDetail/24338?vgnextoid=3fc84c23529d7210VgnVCM100000449c710aRCRD
Canadian Journal of Hospital Pharmacy , VOLUME 64 , NUMBER 4 , July-August 2011