July 28, 2025 • 37 mins
Pharmacists are key partners in helping patients navigate the challenges of managing pain safely and effectively. This episode covers practical strategies for counseling, identifying potential concerns in therapy, and supporting appropriate treatment, plus a quick review of the newly approved non-opioid option. Tune in to strengthen your clinical confidence and improve outcomes in pain care.
HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact
GUEST
Lorin Fisher PharmD, BCACP
Residency Program Director
University of Iowa
Joshua Davis Kinsey and Lorin Fisher have no relevant financial relationships to disclose.
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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Recognize essential counseling points and patterns in medication use that pharmacists should address when managing patients with pain.
2. Describe the role of pharmacists in supporting safe and effective pain management, including awareness of newly approved medications.
0.05 CEU/0.5 Hr
UAN: 0107-0000-25-258-H08-P
Initial release date: 7/28/2025
Expiration date: 7/28/2026
Additional CPE details can be found here.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:03):
Hey, ce Impact subscribers, Welcome to the Game
Changers Clinical Conversationspodcast.
I'm your host, josh Kinsey, and, as always, I'm excited about
our conversation today.
Pain is one of the most commonreasons patients seek care and
one of the most challenging tomanage safely and effectively.
In this episode, we'll explorehow pharmacists can play a
pivotal role in guiding therapy,supporting patients and staying
(00:27):
current on the latest tools andtreatments.
Lauren, it's so great to haveyou today.
We have Lauren Fisher with ustoday as our guest expert.
Thanks for joining us.
Speaker 2 (00:36):
Thanks so much for having me, josh, I appreciate it
.
Speaker 1 (00:38):
Yeah.
So for those listeners outthere who haven't had the
pleasure of meeting you yet oryou've done other work for CE
Impact at different events andsessions, but for those that
haven't met you yet, if you'lltake just a couple minutes,
lauren, to kind of introduceyourself and tell us about your
practice side and your passionsin pharmacy, sure.
Speaker 2 (00:57):
So I'm Lauren Fisher.
I am a clinical assistantprofessor at the University of
Iowa College of Pharmacy in IowaCity, iowa.
In my clinical practice role Iam a clinical pharmacy
specialist at UI Healthcare inthe supportive and palliative
care clinic and, of course,related to my role in academia,
I do research as it relates topalliative care and pain
(01:18):
management, as well as teachthose topics in our PharmD
curriculum and I take APPE andIPPE students on rotation as
well.
I also have a facultyappointment with our Hospice and
Palliative Medicine Fellowshipover at UI Healthcare, so I'm
involved in the training ofthose postgraduate medical
trainees as well.
Speaker 1 (01:39):
Great, you don't sound like you have anything to
do, lauren, so let me see if Ican find you some other tasks.
Speaker 2 (01:47):
I'm sure you can come up with something.
Speaker 1 (01:48):
You sound very busy, so that just further proves my
thanking you for taking out ofyour busy schedule for joining
us today.
So I really appreciate it.
All right.
So, as I mentioned earlier, ourtopic for the day is pain
management.
I always like to set thefoundation for our listeners,
just to make sure thateverybody's remembering things
that they learned in pharmacyschool.
(02:09):
It might be fresh on somepeople's mind, it might be, like
me, where it's 20 years old.
So just kind of resetting thefoundation, so just kind of
remind us the different types ofpain that we may encounter with
our patients and just kind ofoverview of pain management in
general for just a few minuteswith our patients and just kind
of overview of pain managementin general, for just a few
minutes, sure.
Speaker 2 (02:27):
So I think, first thinking about different types
of pain in terms of chronicity,so that breaking it down into
acute pain versus chronic pain.
So acute pain typically occursup to one month following the
time of tissue injury or aninciting incident, so the
development of a tumor that youknow is having a significant
(02:47):
impact on, you know, a givenpart in the body, whereas
chronic pain is pain thatextends three months beyond the
time of what we'd expect to benormal tissue healing.
And then there's this likesubacute pain that, like the CDC
defines as that one to threemonth period.
So that's in terms ofchronicity.
(03:08):
Then I like to think aboutdifferent types of pain in terms
of the character or what it mayfeel like to the patient.
So nociceptive pain, and that isreally like what we typically
think of as acute type pain.
So that's like the sharp pokingtype, sensation type pain.
So that's like the sharp pokingtype sensation and really that
(03:30):
can be due to inflammatory typeconditions.
So either osteorheumatoidarthritis, it can be due to
something like a sunburn, it canbe due to like a cut and that
propagates very fast painsignals to the brain, and that's
why you feel like the sharppoking type sensations.
Neuropathic pain, on the otherhand, usually has more of a
slower conduction, and ittypically occurs when there is
(03:53):
damage to the nociceptive painpathway, and so the typical
types of sensations are that ormore like dull, burning, pins
and needles type sensation.
And then there's this thoughtof something called nociceptic
pain, which is essentially thetransition of more of like acute
nociceptive pain into more oflike a chronic neuropathic pain.
(04:16):
That's related to some types oftopics, like related to
hyperalgesia and allodynia,which maybe we can get into a
little bit more later.
Speaker 1 (04:23):
Okay, interesting.
That's definitely a term I havenot heard before.
What was it again?
Nausea, plastic Nausea plasticpain.
Nausea plastic.
Okay, very interesting.
Yeah, that's a great overview.
So thank you for laying thatfoundation again and just
reminding us of the differenttypes, and I think it's
interesting.
I guess my question is, likepatients who have diabetic
(04:46):
neuropathy, like where, wheredoes that pain fit in?
Like when you mentioned thedifferent types, where would you
put that pain that's in more ofthe chronic right?
I would assume.
Yeah, okay, okay.
Speaker 2 (04:57):
And and definitely along obviously, neuropathic
sensations just based on howpatients typically present with
their with their symptoms, right.
Speaker 1 (05:06):
Okay, okay, I just know that.
That you know, obviously,diabetic patients are a large
chunk of the people that we takecare of as pharmacists, so
that's something to just makesure that that pain falls in
these categories that you weretalking about.
Speaker 2 (05:19):
So, yeah, and I think the other piece I'll just add
real quick is that with Naziplastic pain, excuse me, nazi
septic pain.
Rather it is really more inlike a specific pinpoint
location, the toes and thenspread up the leg.
That's something I alsocommonly see in my clinical
(05:48):
practice related tochemotherapy-induced neuropathy
as well.
So if you're seeing more of aradiation of the pain picture,
it's usually more of a chronicneuropathic picture.
Speaker 1 (05:57):
Got it.
Yeah, that makes sense.
Okay, so it's a burden, rightLike pain is a burden.
It's a burden to the patient.
It's a burden to the healthsystem.
It's a burden, right Like painis a burden.
It's a burden to the patient.
It's a burden to the healthsystem.
It's a burden to the community.
So let's talk about that just alittle bit, that the impact,
the public health impact thatpain has and the prevalence of
pain.
I don't know if you have anysort of stats to share about how
(06:20):
many people present with painor different types.
Speaker 2 (06:24):
Yeah, I was actually glancing at those before we
started.
It's estimated that about 50million Americans experience
chronic pain.
So, like you said, this is asignificant impact and it is
really something that we, aspharmacists, can play a
significant role in addressing.
No matter your practice settingwhether you're an ambulatory
care practice, like myself,whether you're on more of an
(06:45):
acute side and working in ahospital setting, or if you're
in a community practice settingMore often than not you're
probably going to have a patientthat experiences some type of
painful condition.
In terms of like, the impact onlike, function and quality of
life, there can be significantimpacts, so, obviously, reduced
physical functioning, likereduced mobility, fatigue.
(07:07):
Pain can also lead toreductions in social functioning
, so decrease doing recreationalactivities, social activities
that maybe they were able to doprior to the development of the
painful condition, and it canhave an impact on our mental
health as well, developingthings like depression, anxiety
(07:32):
and also suicidality.
A study that I looked at showedthat about 9% of individuals
that committed suicide did havean underlying chronic pain
condition, and I think that'sprobably somewhat of an
underestimation.
So it is a real concern that weshould be taking about, because
pain has such a strong emotionalcomponent.
So, while pain goes through itsneurotransmission and you feel
(07:53):
this is pain, it has to passthrough the limbic system, and
the limbic system is where wedevelop.
Our emotional responses to somany other stressors that we
have in life can really beimpacted when we have a painful
diagnosis on top of that.
So it is really important toview pain in a multifaceted way
(08:15):
and appreciate the strongemotional component with it.
Getting to the financials thatmaybe you asked about, the
estimated national cost forchronic pain is $635 billion per
year.
Billion with a B, that's crazy.
And so what goes into thatcalculation?
Obviously, individual costs topatients, lost productivity at
(08:40):
work and then direct health carecosts as well productivity at
work and then direct healthcarecosts as well.
Over the last decade or more,there's been so much in the news
and at the height of our mindsas pharmacists, related to
opioid epidemic andopioid-related deaths.
I looked at the most recentstatistics for that and it
(09:03):
actually shows, between 2023 and2024, that overdose-related
deaths secondary to opioids hasgone down about 34%, which is
absolutely wonderful.
Speaker 1 (09:15):
That's amazing.
Speaker 2 (09:15):
Yeah, going from about 83,000 deaths in 2023 to
about 55,000 deaths in 2024.
Speaker 1 (09:24):
Wow.
So, Still a long way to go, butstill a long ways to go right,
trending in the right direction.
So, right, yeah, yes, and youknow.
I just would like to reiterate,how you know, pain puts a
burden on the patient's qualityof life in more ways than just
you know.
I feel pain, like you said,it's that whole emotional
(09:45):
component, because if you're notable to go to work, or if
you're not able to go havedinner with your friends, or if
you're not able to exercise, itcan have that emotional stress
and it can, like you said, buildup with depression or anxiety
and eventually lead to suicidalideations as well.
So, yeah, it's definitelysomething to understand.
(10:06):
One thing else I wanted to pointout and maybe talk about a
little bit is patients havedifferent perceptions of pain as
well.
Right, like you know thatthere's the whole.
I don't I think it has fallenout of favor with the pain scale
, but, but you know, you thinkabout that where someone may be
experiencing the same type ofpain, two people and one's going
(10:27):
to feel it a lot more than theother and it's going to be
debilitating more for one thanthe other.
Perhaps, you know, is thereanything like to add to that?
I mean, from your perspectiveof how perception of pain.
Speaker 2 (10:41):
Yeah, so really the numeric rating scale.
So like that, zero to 10 painscale it is so subjective and
really pain in general isextremely subjective due to the
strong emotional component andthe underlying pathophysiology
that could be going on.
One thing that I didn't mentionearlier, when I was talking
(11:02):
about acute versus chronic pain,is that acute pain is natural
and, if anything, it's somewhathealthy.
It's our body's homeostasis torespond to a painful stimulus.
Chronic pain is not.
That is a maladaptive state.
So I think that is important tothink about.
But really, those numeric painratings, I don't really take a
(11:25):
lot of stock in those.
When a patient comes to me inclinic and we're following up on
a analgesic change that we madein the last month.
For me what's most important ishaving an understanding of what
their functional capacity is.
So it is helpful at baseline toknow what is your pain
(11:46):
preventing you from doing, andso I utilize a mnemonic, just
kind of alphabetically PQRSTU,and that U component is how is
your pain affecting you?
And that's something that anypharmacist can ask about.
Some of the other things in thatassessment is P stands for
(12:06):
precipitators or palliators.
What makes pain better, whatmakes it worse?
P, Q quality so what does yourpain feel like to you?
R region radiation we kind oftalked about that a little bit
already.
Right, Severity could be likethat zero to 10, where are you
at?
But sometimes patients reallystruggle with numbers.
So asking about, you know, isthis more of an annoyance?
(12:27):
Is it an aggravation?
Is it preoccupying your mind,Is it excruciating?
So maybe just asking thatseverity question a bit of a
different way.
Timing is it intermittent, Doesit come and go?
When did the pain start?
And then, ultimately, theimpact it has on function.
So, that is a good tool that Ilike to ingrain.
(12:50):
In my mind it's been ingrainedprobably since I was a pharmacy
student, because it's so easy toremember but, again, any
practice that you're in, I feellike that's a really quick and
easy assessment that you can useto ask open-ended questions,
Absolutely easy assessment thatyou can use to ask open-ended
questions?
Speaker 1 (13:05):
Absolutely, and is that something that you
developed or you saw developed,or is there like a place that
our listeners can go to kind ofget that resource and have that?
Speaker 2 (13:14):
No, so I did not develop that it is just
generally speaking, if you lookat lots of different paying
textbooks, this is somethingthat is just generally
recommended for history taking.
Speaker 1 (13:26):
So yeah, okay, that's great.
No, it's good.
I just know that a lot of timesour listeners are not to where
they can write something down,so I want to be sure they can
find that again.
So that's great, great stuff.
And I love how you talked aboutchanging up the numeric scale
into more of like, is itdebilitating, is it excruciating
?
Is it just annoyance?
(13:46):
Is it aggravation?
You know, like, becausesometimes people the words
resonate more with them thanlike.
I know I struggle if I've everhad been in the hospital with
surgery or whatever.
Yeah, it's like I don't knowwhat is.
What is seven mean Like right,exactly.
Is that?
Does that mean I'm just like,yeah, it hurts, I noticed it, so
it's a seven.
Or does that mean, oh, I can'tdo anything because it's
(14:07):
debilitating, so Right?
Speaker 2 (14:08):
Yeah, and as a clinician, like what do we, what
do we do with that number?
Speaker 1 (14:12):
Like Right so.
Speaker 2 (14:13):
So then some people may ask then what is a like a
clinically significant reductionin pain?
Right, so some studies havedetermined that a three-point
reduction on a 0 to 10 scale, solike a 30% reduction, is deemed
to be clinically significant.
But that kind of standard, soto speak, is not universally
(14:38):
applied in all studies analgesicefficacy studies.
So I think that is important tokind of keep in mind.
But then it's like well, whatis a three point reduction
really even mean?
Speaker 1 (14:49):
Yeah, yeah, and, and it, and maybe it makes more
sense to to talk about it in ain a sense of a 30% reduction,
like, are you now 30% moreactive with something because
your pain is gone, or whatever?
So, yeah, very interesting,okay, so we've talked a little
bit about, obviously, thepharmacist is well positioned,
despite, regardless of theirpractice, setting their
(15:10):
opportunities.
So I'd like to dig into some ofthose opportunities.
So we've talked about stayingthat.
There are plenty of tools andresources.
You've mentioned some, sostaying up to date on those is
super important.
Is there anything that you canadd for the listeners about,
like, where to stay up to dateon those is super important.
Is there anything that you canadd for the listeners about,
like, where to stay up to dateon those, or what are some good
tools or resources to kind ofaccess or utilize in this space?
Speaker 2 (15:33):
Absolutely so.
Oftentimes, with analgesics inparticular, we're very concerned
about drug-drug interactions.
So there are a few tools that Ilike to utilize about drug-drug
interactions.
So there are a few tools that Ilike to utilize.
So I definitely use like atypical tertiary resource like
Micrometics LexiComp to makesure that I'm doing a thorough
(15:54):
drug-drug interaction checkthere.
I also utilize a tool fromIndiana University known as the
Flockhart table.
That table what it essentiallydoes is it lists out drugs based
on whether or not it is asubstrate for a cytochrome P450
or SIP enzyme.
And then it lists also whatexamples of inducers or
(16:18):
inhibitors are of that enzymeand so given drugs, and then, to
what degree are they inhibitingor inducing?
Are they a weak, a moderate ora strong inducer?
Or inhibitor so that can bereally helpful, especially if
I'm dealing with a medicationthat has difficult
pharmacokinetic considerationsor pharmacodynamic
(16:39):
considerations like methadone,so that is a really good source
I like to use.
Speaker 1 (16:44):
Or if you're dealing with a patient that has a lot of
comorbidities and they're on alot of medications and yeah,
yeah exactly.
Speaker 2 (16:51):
There's also a tool that I like to use called the
Credible Meds, and I'm sureothers maybe have talked about
it on this podcast, but itessentially is a free resource
that you can you sign up for anaccount and you can determine
the relative risk of QTCprolongation with various
medications Again, differenttypes of analgesics I'll call
(17:15):
out methadone again but alsothings like SNRIs, tricyclic
antidepressants.
We do have to worry about thecumulative risk for QTC
prolongation, especially, likewhat you said earlier, when we
think about patients that mayhave a comorbid cardiac
condition.
So that can be a really greatresource as well.
What I like about it inparticular is that it pulls the
(17:36):
specific studies that cite therelative risks.
So credible meds is a reallygood one.
And then also I think about,like, what the anticholinergic
burden is of given medicationsand while the tertiary resources
like Lexicomp and Micromedexmay calculate that, it may not
(17:57):
be to the level of appreciationthat I'm hoping to get, to kind
of think about what impact couldthis have on the patient.
So the ACB calculator, or theiranticholinergic burden
calculator, is another reallygreat tool I like to use.
Speaker 1 (18:14):
That's a new one for me.
I haven't heard of it.
Yeah it is.
Speaker 2 (18:16):
It is really great.
It kind of similar to, like thetertiary references you can
just type in various medicationsand it can tell you the degree
of high versus moderate, versuslow anticholinergic burden.
So I kind of have a theme ofthinking about, like what is the
cumulative risk of givenmedications for an individual's
patient's condition and as wellas what other conditions they
(18:40):
may have and what othermedications they may be?
Speaker 1 (18:44):
taking.
Yeah, no, that's great.
All great helpful informationand tools and resources.
Medications they may be takingyeah, no, that's great.
All great helpful informationand tools and resources.
So, yeah, sharing those.
So now I want to kind of moveinto talking about specific
treatment, like specific optionsthat are out there.
I think you know talking aboutOTC versus prescription.
We'd be remiss if we didn'ttalk a little bit about the
(19:04):
newest medication on the market.
That's the first non-opioid ina long time.
Yeah.
So yeah, if we can kind of godown the path of talking just a
little bit about reminding uswhat treatment options are out
there OTC prescription, some ofthe newer stuff and just kind of
going into that space for alittle bit, Sure.
Speaker 2 (19:20):
So I mean I'll kind of set the stage a little bit of
talking about the WHO or WorldHealth Organization analgesic
ladder, which I'm sure a lot ofus are familiar from our time in
pharmacy school or just usingit in practice.
So the first rung, or thelowest level for mild pain, we
really should be thinking aboutnon-opioid therapies.
So this can include things likeacetaminophen or NSAIDs, but it
(19:44):
may also include adjuvants aswell, and when I say adjuvants
I'm typically thinking aboutmedications that were not
initially FDA approved for painmanagement but, there's evidence
to show that they haveanalgesic benefits.
So that would be things likeanticonvulsants ranging from
gabapentinoids to sodium channelblockers and SNRIs as well.
(20:05):
Then the next rung is thatmoderate pain, which the WHO
defines as considering usingweak opioids, as well as
non-opioids and adjuvantanalgesics.
Now, what they call weakopioids are tramadol,
hydrocodone, acetaminophen.
Opioids are tramadol,hydrocodone, acetaminophen and
(20:29):
codeine-containing products.
Personally, I have someconcerns with that term weak
opioids, because tramadol andcodeine in particular have
significant pharmacogeneticvariability because of their
involvement with the CYP2D6enzyme, so that can ultimately
have an impact on the efficacyor the non-efficacy of those.
So also, there's really been nohead-to-head studies to show
(20:55):
what opioid may be better thananother one.
So I think the term weak issomething that you know may lead
to a false sense of safety.
Speaker 1 (21:06):
I was gonna say it seems a little misleading if-.
Speaker 2 (21:09):
Exactly, yeah, yeah.
And then the top rung of theanalgesic ladder is for more
persistent and severe pain.
So that would be where we wouldthink of the traditional mu
opioid receptor agonist.
So, like your oxycodone, yourmorphine, your hydromorphone, as
well as using in combinationwith non-opioid analgesics and
(21:32):
adjuvants, and because all ofthose analgesics have different
mechanisms of action along thepain signaling pathway, it
really is important to use amultimodal regimen, so
medications with multiplemechanisms of action right To
get the most bang for your buck.
So I'll circle back to thequestion that you had about the
(21:54):
new medication that was FDAapproved at the end of January,
called Zetrogene.
It became like available,probably for people in practice
to use, around March.
I will give a full disclaimerI've not yet used it in my
practice but I've significantlyinvestigated it because I think
(22:14):
that there could be greatpossibility for future use in
chronic pain, which is the areathat is most relevant to my
clinical practice.
The area that is most relevantto my clinical practice, as
sugetrogene right now only hasan FDA indication for acute pain
management.
Speaker 1 (22:30):
Okay.
Speaker 2 (22:32):
So it is a voltage-gated sodium channel 1.8
inhibitor.
So that particular type ofsodium channel is only present
in the peripheral nervous system.
There's nine different types ofsodium channels and they're
located within the heart, withinthe central nervous system,
within the peripheral nervoussystem.
But 1.7, 1.8 and 1.9, thosethree types of sodium channels
(22:57):
are just in the periphery.
There's currently someinvestigative work looking at
analgesics specific to 1.7 and1.9 right now, but there's
nothing that's FDA approved forthose at this time.
So there are other sodiumchannel blockers that y'all may
be familiar with.
So that can be something likelidocaine, myxillatine,
(23:21):
oxcarbazepine, carbamazepine,lacosamide, but those are
non-specific sodium channelblockers.
So there is a possibility ofhaving neurologic and or
cardiovascular adverse effects.
But what's great withsujetrogene is that it does not
have it's really not been shownto have any of those off-site
(23:41):
adverse effects.
What the two randomizeddouble-blind placebo-controlled
studies have shown is that thereis a less than 5% incidence of
adverse effects with suzetrogene, and the most common being
things like itching, musclespasms and elevated creatine
(24:01):
kinase, which at this point itdoesn't seem like that is
clinically significant.
That elevation, again, since ithas the FDA indication for
acute pain only it really hasnot been studied for longer than
a 14-day duration, and so thatis something to take into
consideration.
(24:22):
There's currently phase twostudies that are going on right
now with sugetrogene for themanagement of lumbosacral
radiculopathy, so that'sbasically low back pain
radiating down to the legs, andthen also for painful diabetic
neuropathy as well.
So we have some preliminaryresults from the lumbosacral
(24:45):
radiculopathy study.
There was a high placebo effectin that study and I feel like
that's just a trouble with doingpain research in general
because there can be really highplacebo effects.
But they are doing a subgroupanalysis and furthering that
study to see if they can not seeas much of a pronounced placebo
(25:06):
effect.
Speaker 1 (25:07):
Okay, interesting.
Yeah, wow, that's a greatoverview of that drug and again,
it's kind of.
I think its promise is big andI'm hopeful that it will
continue with the studies and beable to be indicated for
additional use and be effectiveat that.
It's also interesting to notethat it's not going to have some
(25:28):
of those negative cardio sideeffects and everything like the
others that you mentioned inthat class, so that's good.
Or in a similar class.
Okay, well, that's very helpful.
I was transported for a fewseconds when you were describing
it with the voltage thing.
I thought we were talking aboutsomething totally different.
That's a normal term that wehear talking about medications.
Speaker 2 (25:51):
Yeah, I mean there's so much related to electrical
action, potentials of how ourget transmitted.
So in the peripheral nervoussystem there's so much opening
of those sodium channels, and sothat can be a really great
target for inhibiting furtherpropagation of those signals.
Speaker 1 (26:09):
It's just fascinating how you know research found
that pathway and determine howto kind of work with it.
So yeah, yeah great, it'sreally great.
I'm at a loss for words.
It just sounds, it's so I don'tknow.
It just is so high tech andwe've come so far with drug
research and development, soit's great.
(26:30):
One of the things I wanted totalk about, too is another
opportunity for pharmacists isto really, you know, we always
talk about lifestylemodifications when we're talking
about other comorbid diseasestates, you states like diet and
exercise and things like that,and those things are also super
important and helpful for ourpatients that are undergoing
pain management as well.
(26:51):
So if you can speak just alittle bit about the importance
of activity and sleep and someof those as kind of add-on
therapies to the typicaltreatment for patients, yeah,
definitely Kind of to get tosleep right away.
Speaker 2 (27:05):
If we have a patient that's struggling with sleep,
that can really have an impacton the healing process.
However, if pain is interferingwith sleep, sometimes we may
have to think about optimizingor intensifying our analgesic
regimen to allow the patient tohave adequate sleep.
Now we want it to be good REMsleep, not like an induced sleep
(27:27):
state due to adverse effects ofmedication.
So that's something to thinkabout.
Is you know, do we need tooptimize an analgesic regimen to
allow for adequate sleep?
Exercise can be reallyimportant in enhancing pain,
especially for conditions likefibromyalgia and chronic low
back pain as well, being carefulto be mindful of utilizing like
(27:49):
non-weight-bearing exerciseroutines.
So water aerobics can be areally great tool.
In my clinical practice.
We definitely have functionallimitations for patients living
with serious illnesses likecancer.
So kind of trying to set thoselike functional goals or like
what are they hoping that theycan do?
And so coming up with a plan oflike maybe you know, going out
(28:11):
for a walk a couple of times aweek, getting to go back to
church if they've not been therein so long, and like how can
they have people in their lifehelp them achieve their
functional goals.
So I think that is also reallyimportant to think about, as it
relates to expectation settingand kind of coming back to like,
functionally, what do you wantto be able to do?
(28:32):
And is that realistic in thecontext of your disease?
And your current state of painmanagement.
Speaker 1 (28:38):
Yep, and you segued perfectly into my next point,
which I wanted to get into someof those barriers and challenges
that we face with thesepatients, and one of those is
managing the patientexpectations, and so you spoke
to that very well just recentlyabout how we need to make sure
that we're asking about theirfunction, you know, and
(28:58):
determining.
Did we improve that with theirdrug regimen or the plan that we
had put into place?
So, anything else to talk abouton how to better manage
patients' expectations aroundpain relief.
Speaker 2 (29:11):
I think it's important to be consistent in
asking about expectations,especially even like when we're
leading up to something thatcould have a significant impact
on pain, like a major surgery.
So collaborating with a surgeonpotentially to say you know
what is a realistic expectationfor you know X months out
(29:32):
following the surgery of whatthe patient's pain may be.
Talking to rehabilitationcolleagues like physical
therapists about, you know whatis realistic as it relates to
functional goals.
So, as a pharmacist, we candefinitely forge those
relationships, and that's justreally something I want everyone
(29:52):
, regardless of your clinicalpractice, to think about is how
can you engage withinterprofessional colleagues to
enhance pain management?
Speaker 1 (30:01):
Yeah, I always love opportunities to collaborate, so
thank you for bringing that up.
One thing I'd like to addressto a challenge is the fear of
opioids.
You know, with you mentionedearlier in the last decade or so
, really come into light withthe opioid epidemic and you know
, I think there's a lot of andrightfully so a lot of
(30:22):
negativity around it and a lotof misconceptions as well and
fears.
So how is that some?
How do you approach that in apatient when you see that they
are fearful of going on it andthey really need it, or they're
fearful of you know how long amI going to be on it, or whatever
?
What's some of thoseconversations look like?
Speaker 2 (30:42):
whatever.
What's some of thoseconversations look like?
Yeah, I'll talk about fear inthe context of the patient first
, but I think the opioidepidemic has really sparked fear
, not just with patients butwith the entire medical
community.
Speaker 1 (30:50):
Oh, for sure.
Yeah, even with providers.
Speaker 2 (30:52):
Right, there's been a significant reduction of opioid
prescribing over the opioidepidemic, which is good, where
some of those opioids may be notthe most appropriate thing to
be prescribed.
But what about the patients whomay need them, that are living
with a serious illness and thereis a fear from a primary care
provider or an oncologist toprescribe opioids and then that
leads to undue suffering becauseof that fear.
(31:18):
So I think that that issomething real and I think also
it's something that we aspharmacists should be like
checking as well.
As I see a prescription for alarge quantity of opioids, Like
do I know what the indication is?
Is this something that you knowwould warrant a larger quantity
or a particular opioidselection?
So I think that that'simportant, that, as pharmacists,
(31:39):
that we make sure that we're upto date on education, not just
for you know, thinking aboutopioid stewardship or pain
stewardship, but also forconditions like serious
illnesses that may require kindof some of the outliers as it
relates to high intensity painmanagement that may be with
opioids.
But, to get back to youroriginal question, like for
patients, particularly in myarea of clinical practice in
(32:02):
palliative care, yes, we'represcribing what some people may
think of as high-intensityopioids, so like morphine,
oxycodone, hydromorphone andextender-release opioids as well
like fentanyl and methadone.
And when we call out specificopioids or just bring up the
word opioids, you're right, itcan cause an innate fear and
(32:24):
patients that may be living withstage four cancer ask am I
going to get addicted to this?
So I think it's important that,as pharmacists, we're very
familiar with the termsaddiction, tolerance and
dependence, because those threeterms can be confusing.
For us they can be confusing,but also for patients as well.
For us, they can be confusing,but also for patients as well.
So addiction is inappropriateuse of any medication opioids in
(32:48):
this example and that couldlead to possible diversion.
So using opioids for thingsother than pain and trying to
acquire them by otherinappropriate means.
Tolerance is essentially whenan individual is on a dose of a
medication and after a prolongedperiod of time, that dose is no
(33:09):
longer effective.
It's a biological phenomenon.
Josh, if you and I were onopioids, if for a period of time
, tolerance would happen to us.
So that is expected and to benormal, and I tell patients that
if that occurs, that's when wethink about doing a rotation to
a different opioid medicine, orto think about increasing or
(33:30):
changing the dose.
And then dependence essentiallymeans that if an individual
were to rapidly discontinue orjust stop taking their opioid
medication, they wouldexperience withdrawal effects.
Or just stop taking theiropioid medication, they would
experience withdrawal effects.
So withdrawal effects meaningthings like diarrhea, worsening
pain, nausea, vomiting, chills,tremor, that type of thing, and
(33:53):
again, that would be somethingthat you and I would experience
as well if we were in thatsituation.
And so I think normalizingespecially tolerance and
dependence, are things that wewould expect to happen under
specific scenarios is importantfor patients to know, and then
we also, you know, providereassurance that they're taking
opioids for a legitimate medicalpurpose.
Speaker 1 (34:15):
Yeah yeah, I love that explanation that you just
gave, like that was so good.
The addiction versus toleranceversus dependence I mean that I
feel like sometimes they justget thrown into the same
category and it's all viewed asnegative and it's all viewed as
like risk behavior and whatever.
So I really appreciate thatfurther explanation on that.
(34:35):
That was really helpful.
Well, unfortunately we'rerunning out of time.
What else, Lauren?
Is there anything else in thespace that you really wanted to
be sure that you shared with ourlisteners today, before we
start wrapping up, Anything elsethat you want to infer upon?
Speaker 2 (34:51):
Sure, I mean, I think , just to emphasize the point
that I made earlier from theperspective of opioids and just
pain in general.
It can seem very complicated,very scary, there can be a
stigma associated with it, butas pharmacists, we are some of
the most accessible healthcareprofessionals and it's essential
that we remain educated in thisarea and also to approach pain
(35:16):
management with a sense ofcuriosity and concern for the
patient, not necessarily asbeing a gatekeeper, looking for
red flags, so to speak, and kindof being on the defensive.
It's really important, you know,to connect with your patient,
to inquire about how they may betaking their pain medications
(35:37):
and how they may be able to help, whether it's connecting with a
provider that they may beworking with, whether it's
giving recommendations aboutdose adjustments, whether it is
talking to providers about sideeffects we really play a pivotal
role.
Speaker 1 (35:48):
Yeah, absolutely, that's great.
You know, I always taught mystudents when I was in academia
we have to be sleuths and I'vementioned that before on the
podcast, my favorite team, oneof my favorite TV shows of all
time is Murder.
She Wrote, and I love just howinquisitive she is and how JB
Fletcher always asks thequestions, and so I used to
always tell them you got to belike a JB Fletcher, you have to
(36:08):
ask the questions, write downthe information, put the pieces
of the puzzle together, and Ithink that is exactly what
you're saying with thesepatients as well.
So, rather than initiallyjumping to conclusions, or oh,
it's a, it's an opioidprescription.
It's definitely a red flag.
What are they diverting it?
You know, whatever it's askingthe questions trying to
understand, you may not realizethat they've just went through a
(36:30):
cancer diagnosis, you may notrealize that they're undergoing
some other type of treatment, or, or you know, surgery or
something.
So, so, yeah, I think it'sreally important that we're
asking the right questions andthen making an informed decision
as that provider for them.
So, yeah, such great stuff,lauren.
Thank you so much.
This was very, very helpful andjust kind of reminding us all
(36:53):
about pain management and how itis complex, but yet it's not
that complex, it's doable, rightLike.
It's something that we shouldall have a hand in and we should
all be doing so well.
Thanks again.
Super appreciate you spendingtime out of your busy schedule.
So thank you.
Speaker 2 (37:09):
Yes, thank you for having me.
I appreciate it.
Speaker 1 (37:11):
Absolutely.
If you're a CE plan subscriber,be sure to claim your CE credit
for this episode of GameChangers by logging in at
CEimpactcom.
And, as always, have a greatweek and keep learning.
I can't wait to dig intoanother game-changing topic with
you all next week.
Hey, ce Impact subscribers, Welcome to the Game
Changers Clinical Conversationspodcast.
I'm your host, josh Kinsey, and, as always, I'm excited about
our conversation today.
Pain is one of the most commonreasons patients seek care and
one of the most challenging tomanage safely and effectively.
In this episode, we'll explorehow pharmacists can play a
pivotal role in guiding therapy,supporting patients and staying
(00:27):
current on the latest tools andtreatments.
Lauren, it's so great to haveyou today.
We have Lauren Fisher with ustoday as our guest expert.
Thanks for joining us.
Speaker 2 (00:36):
Thanks so much for having me, josh, I appreciate it
.
Speaker 1 (00:38):
Yeah.
So for those listeners outthere who haven't had the
pleasure of meeting you yet oryou've done other work for CE
Impact at different events andsessions, but for those that
haven't met you yet, if you'lltake just a couple minutes,
lauren, to kind of introduceyourself and tell us about your
practice side and your passionsin pharmacy, sure.
Speaker 2 (00:57):
So I'm Lauren Fisher.
I am a clinical assistantprofessor at the University of
Iowa College of Pharmacy in IowaCity, iowa.
In my clinical practice role Iam a clinical pharmacy
specialist at UI Healthcare inthe supportive and palliative
care clinic and, of course,related to my role in academia,
I do research as it relates topalliative care and pain
(01:18):
management, as well as teachthose topics in our PharmD
curriculum and I take APPE andIPPE students on rotation as
well.
I also have a facultyappointment with our Hospice and
Palliative Medicine Fellowshipover at UI Healthcare, so I'm
involved in the training ofthose postgraduate medical
trainees as well.
Speaker 1 (01:39):
Great, you don't sound like you have anything to
do, lauren, so let me see if Ican find you some other tasks.
Speaker 2 (01:47):
I'm sure you can come up with something.
Speaker 1 (01:48):
You sound very busy, so that just further proves my
thanking you for taking out ofyour busy schedule for joining
us today.
So I really appreciate it.
All right.
So, as I mentioned earlier, ourtopic for the day is pain
management.
I always like to set thefoundation for our listeners,
just to make sure thateverybody's remembering things
that they learned in pharmacyschool.
(02:09):
It might be fresh on somepeople's mind, it might be, like
me, where it's 20 years old.
So just kind of resetting thefoundation, so just kind of
remind us the different types ofpain that we may encounter with
our patients and just kind ofoverview of pain management in
general for just a few minuteswith our patients and just kind
of overview of pain managementin general, for just a few
minutes, sure.
Speaker 2 (02:27):
So I think, first thinking about different types
of pain in terms of chronicity,so that breaking it down into
acute pain versus chronic pain.
So acute pain typically occursup to one month following the
time of tissue injury or aninciting incident, so the
development of a tumor that youknow is having a significant
(02:47):
impact on, you know, a givenpart in the body, whereas
chronic pain is pain thatextends three months beyond the
time of what we'd expect to benormal tissue healing.
And then there's this likesubacute pain that, like the CDC
defines as that one to threemonth period.
So that's in terms ofchronicity.
(03:08):
Then I like to think aboutdifferent types of pain in terms
of the character or what it mayfeel like to the patient.
So nociceptive pain, and that isreally like what we typically
think of as acute type pain.
So that's like the sharp pokingtype, sensation type pain.
So that's like the sharp pokingtype sensation and really that
(03:30):
can be due to inflammatory typeconditions.
So either osteorheumatoidarthritis, it can be due to
something like a sunburn, it canbe due to like a cut and that
propagates very fast painsignals to the brain, and that's
why you feel like the sharppoking type sensations.
Neuropathic pain, on the otherhand, usually has more of a
slower conduction, and ittypically occurs when there is
(03:53):
damage to the nociceptive painpathway, and so the typical
types of sensations are that ormore like dull, burning, pins
and needles type sensation.
And then there's this thoughtof something called nociceptic
pain, which is essentially thetransition of more of like acute
nociceptive pain into more oflike a chronic neuropathic pain.
(04:16):
That's related to some types oftopics, like related to
hyperalgesia and allodynia,which maybe we can get into a
little bit more later.
Speaker 1 (04:23):
Okay, interesting.
That's definitely a term I havenot heard before.
What was it again?
Nausea, plastic Nausea plasticpain.
Nausea plastic.
Okay, very interesting.
Yeah, that's a great overview.
So thank you for laying thatfoundation again and just
reminding us of the differenttypes, and I think it's
interesting.
I guess my question is, likepatients who have diabetic
(04:46):
neuropathy, like where, wheredoes that pain fit in?
Like when you mentioned thedifferent types, where would you
put that pain that's in more ofthe chronic right?
I would assume.
Yeah, okay, okay.
Speaker 2 (04:57):
And and definitely along obviously, neuropathic
sensations just based on howpatients typically present with
their with their symptoms, right.
Speaker 1 (05:06):
Okay, okay, I just know that.
That you know, obviously,diabetic patients are a large
chunk of the people that we takecare of as pharmacists, so
that's something to just makesure that that pain falls in
these categories that you weretalking about.
Speaker 2 (05:19):
So, yeah, and I think the other piece I'll just add
real quick is that with Naziplastic pain, excuse me, nazi
septic pain.
Rather it is really more inlike a specific pinpoint
location, the toes and thenspread up the leg.
That's something I alsocommonly see in my clinical
(05:48):
practice related tochemotherapy-induced neuropathy
as well.
So if you're seeing more of aradiation of the pain picture,
it's usually more of a chronicneuropathic picture.
Speaker 1 (05:57):
Got it.
Yeah, that makes sense.
Okay, so it's a burden, rightLike pain is a burden.
It's a burden to the patient.
It's a burden to the healthsystem.
It's a burden, right Like painis a burden.
It's a burden to the patient.
It's a burden to the healthsystem.
It's a burden to the community.
So let's talk about that just alittle bit, that the impact,
the public health impact thatpain has and the prevalence of
pain.
I don't know if you have anysort of stats to share about how
(06:20):
many people present with painor different types.
Speaker 2 (06:24):
Yeah, I was actually glancing at those before we
started.
It's estimated that about 50million Americans experience
chronic pain.
So, like you said, this is asignificant impact and it is
really something that we, aspharmacists, can play a
significant role in addressing.
No matter your practice settingwhether you're an ambulatory
care practice, like myself,whether you're on more of an
(06:45):
acute side and working in ahospital setting, or if you're
in a community practice settingMore often than not you're
probably going to have a patientthat experiences some type of
painful condition.
In terms of like, the impact onlike, function and quality of
life, there can be significantimpacts, so, obviously, reduced
physical functioning, likereduced mobility, fatigue.
(07:07):
Pain can also lead toreductions in social functioning
, so decrease doing recreationalactivities, social activities
that maybe they were able to doprior to the development of the
painful condition, and it canhave an impact on our mental
health as well, developingthings like depression, anxiety
(07:32):
and also suicidality.
A study that I looked at showedthat about 9% of individuals
that committed suicide did havean underlying chronic pain
condition, and I think that'sprobably somewhat of an
underestimation.
So it is a real concern that weshould be taking about, because
pain has such a strong emotionalcomponent.
So, while pain goes through itsneurotransmission and you feel
(07:53):
this is pain, it has to passthrough the limbic system, and
the limbic system is where wedevelop.
Our emotional responses to somany other stressors that we
have in life can really beimpacted when we have a painful
diagnosis on top of that.
So it is really important toview pain in a multifaceted way
(08:15):
and appreciate the strongemotional component with it.
Getting to the financials thatmaybe you asked about, the
estimated national cost forchronic pain is $635 billion per
year.
Billion with a B, that's crazy.
And so what goes into thatcalculation?
Obviously, individual costs topatients, lost productivity at
(08:40):
work and then direct health carecosts as well productivity at
work and then direct healthcarecosts as well.
Over the last decade or more,there's been so much in the news
and at the height of our mindsas pharmacists, related to
opioid epidemic andopioid-related deaths.
I looked at the most recentstatistics for that and it
(09:03):
actually shows, between 2023 and2024, that overdose-related
deaths secondary to opioids hasgone down about 34%, which is
absolutely wonderful.
Speaker 1 (09:15):
That's amazing.
Speaker 2 (09:15):
Yeah, going from about 83,000 deaths in 2023 to
about 55,000 deaths in 2024.
Speaker 1 (09:24):
Wow.
So, Still a long way to go, butstill a long ways to go right,
trending in the right direction.
So, right, yeah, yes, and youknow.
I just would like to reiterate,how you know, pain puts a
burden on the patient's qualityof life in more ways than just
you know.
I feel pain, like you said,it's that whole emotional
(09:45):
component, because if you're notable to go to work, or if
you're not able to go havedinner with your friends, or if
you're not able to exercise, itcan have that emotional stress
and it can, like you said, buildup with depression or anxiety
and eventually lead to suicidalideations as well.
So, yeah, it's definitelysomething to understand.
(10:06):
One thing else I wanted to pointout and maybe talk about a
little bit is patients havedifferent perceptions of pain as
well.
Right, like you know thatthere's the whole.
I don't I think it has fallenout of favor with the pain scale
, but, but you know, you thinkabout that where someone may be
experiencing the same type ofpain, two people and one's going
(10:27):
to feel it a lot more than theother and it's going to be
debilitating more for one thanthe other.
Perhaps, you know, is thereanything like to add to that?
I mean, from your perspectiveof how perception of pain.
Speaker 2 (10:41):
Yeah, so really the numeric rating scale.
So like that, zero to 10 painscale it is so subjective and
really pain in general isextremely subjective due to the
strong emotional component andthe underlying pathophysiology
that could be going on.
One thing that I didn't mentionearlier, when I was talking
(11:02):
about acute versus chronic pain,is that acute pain is natural
and, if anything, it's somewhathealthy.
It's our body's homeostasis torespond to a painful stimulus.
Chronic pain is not.
That is a maladaptive state.
So I think that is important tothink about.
But really, those numeric painratings, I don't really take a
(11:25):
lot of stock in those.
When a patient comes to me inclinic and we're following up on
a analgesic change that we madein the last month.
For me what's most important ishaving an understanding of what
their functional capacity is.
So it is helpful at baseline toknow what is your pain
(11:46):
preventing you from doing, andso I utilize a mnemonic, just
kind of alphabetically PQRSTU,and that U component is how is
your pain affecting you?
And that's something that anypharmacist can ask about.
Some of the other things in thatassessment is P stands for
(12:06):
precipitators or palliators.
What makes pain better, whatmakes it worse?
P, Q quality so what does yourpain feel like to you?
R region radiation we kind oftalked about that a little bit
already.
Right, Severity could be likethat zero to 10, where are you
at?
But sometimes patients reallystruggle with numbers.
So asking about, you know, isthis more of an annoyance?
(12:27):
Is it an aggravation?
Is it preoccupying your mind,Is it excruciating?
So maybe just asking thatseverity question a bit of a
different way.
Timing is it intermittent, Doesit come and go?
When did the pain start?
And then, ultimately, theimpact it has on function.
So, that is a good tool that Ilike to ingrain.
(12:50):
In my mind it's been ingrainedprobably since I was a pharmacy
student, because it's so easy toremember but, again, any
practice that you're in, I feellike that's a really quick and
easy assessment that you can useto ask open-ended questions,
Absolutely easy assessment thatyou can use to ask open-ended
questions?
Speaker 1 (13:05):
Absolutely, and is that something that you
developed or you saw developed,or is there like a place that
our listeners can go to kind ofget that resource and have that?
Speaker 2 (13:14):
No, so I did not develop that it is just
generally speaking, if you lookat lots of different paying
textbooks, this is somethingthat is just generally
recommended for history taking.
Speaker 1 (13:26):
So yeah, okay, that's great.
No, it's good.
I just know that a lot of timesour listeners are not to where
they can write something down,so I want to be sure they can
find that again.
So that's great, great stuff.
And I love how you talked aboutchanging up the numeric scale
into more of like, is itdebilitating, is it excruciating
?
Is it just annoyance?
(13:46):
Is it aggravation?
You know, like, becausesometimes people the words
resonate more with them thanlike.
I know I struggle if I've everhad been in the hospital with
surgery or whatever.
Yeah, it's like I don't knowwhat is.
What is seven mean Like right,exactly.
Is that?
Does that mean I'm just like,yeah, it hurts, I noticed it, so
it's a seven.
Or does that mean, oh, I can'tdo anything because it's
(14:07):
debilitating, so Right?
Speaker 2 (14:08):
Yeah, and as a clinician, like what do we, what
do we do with that number?
Speaker 1 (14:12):
Like Right so.
Speaker 2 (14:13):
So then some people may ask then what is a like a
clinically significant reductionin pain?
Right, so some studies havedetermined that a three-point
reduction on a 0 to 10 scale, solike a 30% reduction, is deemed
to be clinically significant.
But that kind of standard, soto speak, is not universally
(14:38):
applied in all studies analgesicefficacy studies.
So I think that is important tokind of keep in mind.
But then it's like well, whatis a three point reduction
really even mean?
Speaker 1 (14:49):
Yeah, yeah, and, and it, and maybe it makes more
sense to to talk about it in ain a sense of a 30% reduction,
like, are you now 30% moreactive with something because
your pain is gone, or whatever?
So, yeah, very interesting,okay, so we've talked a little
bit about, obviously, thepharmacist is well positioned,
despite, regardless of theirpractice, setting their
(15:10):
opportunities.
So I'd like to dig into some ofthose opportunities.
So we've talked about stayingthat.
There are plenty of tools andresources.
You've mentioned some, sostaying up to date on those is
super important.
Is there anything that you canadd for the listeners about,
like, where to stay up to dateon those is super important.
Is there anything that you canadd for the listeners about,
like, where to stay up to dateon those, or what are some good
tools or resources to kind ofaccess or utilize in this space?
Speaker 2 (15:33):
Absolutely so.
Oftentimes, with analgesics inparticular, we're very concerned
about drug-drug interactions.
So there are a few tools that Ilike to utilize about drug-drug
interactions.
So there are a few tools that Ilike to utilize.
So I definitely use like atypical tertiary resource like
Micrometics LexiComp to makesure that I'm doing a thorough
(15:54):
drug-drug interaction checkthere.
I also utilize a tool fromIndiana University known as the
Flockhart table.
That table what it essentiallydoes is it lists out drugs based
on whether or not it is asubstrate for a cytochrome P450
or SIP enzyme.
And then it lists also whatexamples of inducers or
(16:18):
inhibitors are of that enzymeand so given drugs, and then, to
what degree are they inhibitingor inducing?
Are they a weak, a moderate ora strong inducer?
Or inhibitor so that can bereally helpful, especially if
I'm dealing with a medicationthat has difficult
pharmacokinetic considerationsor pharmacodynamic
(16:39):
considerations like methadone,so that is a really good source
I like to use.
Speaker 1 (16:44):
Or if you're dealing with a patient that has a lot of
comorbidities and they're on alot of medications and yeah,
yeah exactly.
Speaker 2 (16:51):
There's also a tool that I like to use called the
Credible Meds, and I'm sureothers maybe have talked about
it on this podcast, but itessentially is a free resource
that you can you sign up for anaccount and you can determine
the relative risk of QTCprolongation with various
medications Again, differenttypes of analgesics I'll call
(17:15):
out methadone again but alsothings like SNRIs, tricyclic
antidepressants.
We do have to worry about thecumulative risk for QTC
prolongation, especially, likewhat you said earlier, when we
think about patients that mayhave a comorbid cardiac
condition.
So that can be a really greatresource as well.
What I like about it inparticular is that it pulls the
(17:36):
specific studies that cite therelative risks.
So credible meds is a reallygood one.
And then also I think about,like, what the anticholinergic
burden is of given medicationsand while the tertiary resources
like Lexicomp and Micromedexmay calculate that, it may not
(17:57):
be to the level of appreciationthat I'm hoping to get, to kind
of think about what impact couldthis have on the patient.
So the ACB calculator, or theiranticholinergic burden
calculator, is another reallygreat tool I like to use.
Speaker 1 (18:14):
That's a new one for me.
I haven't heard of it.
Yeah it is.
Speaker 2 (18:16):
It is really great.
It kind of similar to, like thetertiary references you can
just type in various medicationsand it can tell you the degree
of high versus moderate, versuslow anticholinergic burden.
So I kind of have a theme ofthinking about, like what is the
cumulative risk of givenmedications for an individual's
patient's condition and as wellas what other conditions they
(18:40):
may have and what othermedications they may be?
Speaker 1 (18:44):
taking.
Yeah, no, that's great.
All great helpful informationand tools and resources.
Medications they may be takingyeah, no, that's great.
All great helpful informationand tools and resources.
So, yeah, sharing those.
So now I want to kind of moveinto talking about specific
treatment, like specific optionsthat are out there.
I think you know talking aboutOTC versus prescription.
We'd be remiss if we didn'ttalk a little bit about the
(19:04):
newest medication on the market.
That's the first non-opioid ina long time.
Yeah.
So yeah, if we can kind of godown the path of talking just a
little bit about reminding uswhat treatment options are out
there OTC prescription, some ofthe newer stuff and just kind of
going into that space for alittle bit, Sure.
Speaker 2 (19:20):
So I mean I'll kind of set the stage a little bit of
talking about the WHO or WorldHealth Organization analgesic
ladder, which I'm sure a lot ofus are familiar from our time in
pharmacy school or just usingit in practice.
So the first rung, or thelowest level for mild pain, we
really should be thinking aboutnon-opioid therapies.
So this can include things likeacetaminophen or NSAIDs, but it
(19:44):
may also include adjuvants aswell, and when I say adjuvants
I'm typically thinking aboutmedications that were not
initially FDA approved for painmanagement but, there's evidence
to show that they haveanalgesic benefits.
So that would be things likeanticonvulsants ranging from
gabapentinoids to sodium channelblockers and SNRIs as well.
(20:05):
Then the next rung is thatmoderate pain, which the WHO
defines as considering usingweak opioids, as well as
non-opioids and adjuvantanalgesics.
Now, what they call weakopioids are tramadol,
hydrocodone, acetaminophen.
Opioids are tramadol,hydrocodone, acetaminophen and
(20:29):
codeine-containing products.
Personally, I have someconcerns with that term weak
opioids, because tramadol andcodeine in particular have
significant pharmacogeneticvariability because of their
involvement with the CYP2D6enzyme, so that can ultimately
have an impact on the efficacyor the non-efficacy of those.
So also, there's really been nohead-to-head studies to show
(20:55):
what opioid may be better thananother one.
So I think the term weak issomething that you know may lead
to a false sense of safety.
Speaker 1 (21:06):
I was gonna say it seems a little misleading if-.
Speaker 2 (21:09):
Exactly, yeah, yeah.
And then the top rung of theanalgesic ladder is for more
persistent and severe pain.
So that would be where we wouldthink of the traditional mu
opioid receptor agonist.
So, like your oxycodone, yourmorphine, your hydromorphone, as
well as using in combinationwith non-opioid analgesics and
(21:32):
adjuvants, and because all ofthose analgesics have different
mechanisms of action along thepain signaling pathway, it
really is important to use amultimodal regimen, so
medications with multiplemechanisms of action right To
get the most bang for your buck.
So I'll circle back to thequestion that you had about the
(21:54):
new medication that was FDAapproved at the end of January,
called Zetrogene.
It became like available,probably for people in practice
to use, around March.
I will give a full disclaimerI've not yet used it in my
practice but I've significantlyinvestigated it because I think
(22:14):
that there could be greatpossibility for future use in
chronic pain, which is the areathat is most relevant to my
clinical practice.
The area that is most relevantto my clinical practice, as
sugetrogene right now only hasan FDA indication for acute pain
management.
Speaker 1 (22:30):
Okay.
Speaker 2 (22:32):
So it is a voltage-gated sodium channel 1.8
inhibitor.
So that particular type ofsodium channel is only present
in the peripheral nervous system.
There's nine different types ofsodium channels and they're
located within the heart, withinthe central nervous system,
within the peripheral nervoussystem.
But 1.7, 1.8 and 1.9, thosethree types of sodium channels
(22:57):
are just in the periphery.
There's currently someinvestigative work looking at
analgesics specific to 1.7 and1.9 right now, but there's
nothing that's FDA approved forthose at this time.
So there are other sodiumchannel blockers that y'all may
be familiar with.
So that can be something likelidocaine, myxillatine,
(23:21):
oxcarbazepine, carbamazepine,lacosamide, but those are
non-specific sodium channelblockers.
So there is a possibility ofhaving neurologic and or
cardiovascular adverse effects.
But what's great withsujetrogene is that it does not
have it's really not been shownto have any of those off-site
(23:41):
adverse effects.
What the two randomizeddouble-blind placebo-controlled
studies have shown is that thereis a less than 5% incidence of
adverse effects with suzetrogene, and the most common being
things like itching, musclespasms and elevated creatine
(24:01):
kinase, which at this point itdoesn't seem like that is
clinically significant.
That elevation, again, since ithas the FDA indication for
acute pain only it really hasnot been studied for longer than
a 14-day duration, and so thatis something to take into
consideration.
(24:22):
There's currently phase twostudies that are going on right
now with sugetrogene for themanagement of lumbosacral
radiculopathy, so that'sbasically low back pain
radiating down to the legs, andthen also for painful diabetic
neuropathy as well.
So we have some preliminaryresults from the lumbosacral
(24:45):
radiculopathy study.
There was a high placebo effectin that study and I feel like
that's just a trouble with doingpain research in general
because there can be really highplacebo effects.
But they are doing a subgroupanalysis and furthering that
study to see if they can not seeas much of a pronounced placebo
(25:06):
effect.
Speaker 1 (25:07):
Okay, interesting.
Yeah, wow, that's a greatoverview of that drug and again,
it's kind of.
I think its promise is big andI'm hopeful that it will
continue with the studies and beable to be indicated for
additional use and be effectiveat that.
It's also interesting to notethat it's not going to have some
(25:28):
of those negative cardio sideeffects and everything like the
others that you mentioned inthat class, so that's good.
Or in a similar class.
Okay, well, that's very helpful.
I was transported for a fewseconds when you were describing
it with the voltage thing.
I thought we were talking aboutsomething totally different.
That's a normal term that wehear talking about medications.
Speaker 2 (25:51):
Yeah, I mean there's so much related to electrical
action, potentials of how ourget transmitted.
So in the peripheral nervoussystem there's so much opening
of those sodium channels, and sothat can be a really great
target for inhibiting furtherpropagation of those signals.
Speaker 1 (26:09):
It's just fascinating how you know research found
that pathway and determine howto kind of work with it.
So yeah, yeah great, it'sreally great.
I'm at a loss for words.
It just sounds, it's so I don'tknow.
It just is so high tech andwe've come so far with drug
research and development, soit's great.
(26:30):
One of the things I wanted totalk about, too is another
opportunity for pharmacists isto really, you know, we always
talk about lifestylemodifications when we're talking
about other comorbid diseasestates, you states like diet and
exercise and things like that,and those things are also super
important and helpful for ourpatients that are undergoing
pain management as well.
(26:51):
So if you can speak just alittle bit about the importance
of activity and sleep and someof those as kind of add-on
therapies to the typicaltreatment for patients, yeah,
definitely Kind of to get tosleep right away.
Speaker 2 (27:05):
If we have a patient that's struggling with sleep,
that can really have an impacton the healing process.
However, if pain is interferingwith sleep, sometimes we may
have to think about optimizingor intensifying our analgesic
regimen to allow the patient tohave adequate sleep.
Now we want it to be good REMsleep, not like an induced sleep
(27:27):
state due to adverse effects ofmedication.
So that's something to thinkabout.
Is you know, do we need tooptimize an analgesic regimen to
allow for adequate sleep?
Exercise can be reallyimportant in enhancing pain,
especially for conditions likefibromyalgia and chronic low
back pain as well, being carefulto be mindful of utilizing like
(27:49):
non-weight-bearing exerciseroutines.
So water aerobics can be areally great tool.
In my clinical practice.
We definitely have functionallimitations for patients living
with serious illnesses likecancer.
So kind of trying to set thoselike functional goals or like
what are they hoping that theycan do?
And so coming up with a plan oflike maybe you know, going out
(28:11):
for a walk a couple of times aweek, getting to go back to
church if they've not been therein so long, and like how can
they have people in their lifehelp them achieve their
functional goals.
So I think that is also reallyimportant to think about, as it
relates to expectation settingand kind of coming back to like,
functionally, what do you wantto be able to do?
(28:32):
And is that realistic in thecontext of your disease?
And your current state of painmanagement.
Speaker 1 (28:38):
Yep, and you segued perfectly into my next point,
which I wanted to get into someof those barriers and challenges
that we face with thesepatients, and one of those is
managing the patientexpectations, and so you spoke
to that very well just recentlyabout how we need to make sure
that we're asking about theirfunction, you know, and
(28:58):
determining.
Did we improve that with theirdrug regimen or the plan that we
had put into place?
So, anything else to talk abouton how to better manage
patients' expectations aroundpain relief.
Speaker 2 (29:11):
I think it's important to be consistent in
asking about expectations,especially even like when we're
leading up to something thatcould have a significant impact
on pain, like a major surgery.
So collaborating with a surgeonpotentially to say you know
what is a realistic expectationfor you know X months out
(29:32):
following the surgery of whatthe patient's pain may be.
Talking to rehabilitationcolleagues like physical
therapists about, you know whatis realistic as it relates to
functional goals.
So, as a pharmacist, we candefinitely forge those
relationships, and that's justreally something I want everyone
(29:52):
, regardless of your clinicalpractice, to think about is how
can you engage withinterprofessional colleagues to
enhance pain management?
Speaker 1 (30:01):
Yeah, I always love opportunities to collaborate, so
thank you for bringing that up.
One thing I'd like to addressto a challenge is the fear of
opioids.
You know, with you mentionedearlier in the last decade or so
, really come into light withthe opioid epidemic and you know
, I think there's a lot of andrightfully so a lot of
(30:22):
negativity around it and a lotof misconceptions as well and
fears.
So how is that some?
How do you approach that in apatient when you see that they
are fearful of going on it andthey really need it, or they're
fearful of you know how long amI going to be on it, or whatever
?
What's some of thoseconversations look like?
Speaker 2 (30:42):
whatever.
What's some of thoseconversations look like?
Yeah, I'll talk about fear inthe context of the patient first
, but I think the opioidepidemic has really sparked fear
, not just with patients butwith the entire medical
community.
Speaker 1 (30:50):
Oh, for sure.
Yeah, even with providers.
Speaker 2 (30:52):
Right, there's been a significant reduction of opioid
prescribing over the opioidepidemic, which is good, where
some of those opioids may be notthe most appropriate thing to
be prescribed.
But what about the patients whomay need them, that are living
with a serious illness and thereis a fear from a primary care
provider or an oncologist toprescribe opioids and then that
leads to undue suffering becauseof that fear.
(31:18):
So I think that that issomething real and I think also
it's something that we aspharmacists should be like
checking as well.
As I see a prescription for alarge quantity of opioids, Like
do I know what the indication is?
Is this something that you knowwould warrant a larger quantity
or a particular opioidselection?
So I think that that'simportant, that, as pharmacists,
(31:39):
that we make sure that we're upto date on education, not just
for you know, thinking aboutopioid stewardship or pain
stewardship, but also forconditions like serious
illnesses that may require kindof some of the outliers as it
relates to high intensity painmanagement that may be with
opioids.
But, to get back to youroriginal question, like for
patients, particularly in myarea of clinical practice in
(32:02):
palliative care, yes, we'represcribing what some people may
think of as high-intensityopioids, so like morphine,
oxycodone, hydromorphone andextender-release opioids as well
like fentanyl and methadone.
And when we call out specificopioids or just bring up the
word opioids, you're right, itcan cause an innate fear and
(32:24):
patients that may be living withstage four cancer ask am I
going to get addicted to this?
So I think it's important that,as pharmacists, we're very
familiar with the termsaddiction, tolerance and
dependence, because those threeterms can be confusing.
For us they can be confusing,but also for patients as well.
For us, they can be confusing,but also for patients as well.
So addiction is inappropriateuse of any medication opioids in
(32:48):
this example and that couldlead to possible diversion.
So using opioids for thingsother than pain and trying to
acquire them by otherinappropriate means.
Tolerance is essentially whenan individual is on a dose of a
medication and after a prolongedperiod of time, that dose is no
(33:09):
longer effective.
It's a biological phenomenon.
Josh, if you and I were onopioids, if for a period of time
, tolerance would happen to us.
So that is expected and to benormal, and I tell patients that
if that occurs, that's when wethink about doing a rotation to
a different opioid medicine, orto think about increasing or
(33:30):
changing the dose.
And then dependence essentiallymeans that if an individual
were to rapidly discontinue orjust stop taking their opioid
medication, they wouldexperience withdrawal effects.
Or just stop taking theiropioid medication, they would
experience withdrawal effects.
So withdrawal effects meaningthings like diarrhea, worsening
pain, nausea, vomiting, chills,tremor, that type of thing, and
(33:53):
again, that would be somethingthat you and I would experience
as well if we were in thatsituation.
And so I think normalizingespecially tolerance and
dependence, are things that wewould expect to happen under
specific scenarios is importantfor patients to know, and then
we also, you know, providereassurance that they're taking
opioids for a legitimate medicalpurpose.
Speaker 1 (34:15):
Yeah yeah, I love that explanation that you just
gave, like that was so good.
The addiction versus toleranceversus dependence I mean that I
feel like sometimes they justget thrown into the same
category and it's all viewed asnegative and it's all viewed as
like risk behavior and whatever.
So I really appreciate thatfurther explanation on that.
(34:35):
That was really helpful.
Well, unfortunately we'rerunning out of time.
What else, Lauren?
Is there anything else in thespace that you really wanted to
be sure that you shared with ourlisteners today, before we
start wrapping up, Anything elsethat you want to infer upon?
Speaker 2 (34:51):
Sure, I mean, I think , just to emphasize the point
that I made earlier from theperspective of opioids and just
pain in general.
It can seem very complicated,very scary, there can be a
stigma associated with it, butas pharmacists, we are some of
the most accessible healthcareprofessionals and it's essential
that we remain educated in thisarea and also to approach pain
(35:16):
management with a sense ofcuriosity and concern for the
patient, not necessarily asbeing a gatekeeper, looking for
red flags, so to speak, and kindof being on the defensive.
It's really important, you know,to connect with your patient,
to inquire about how they may betaking their pain medications
(35:37):
and how they may be able to help, whether it's connecting with a
provider that they may beworking with, whether it's
giving recommendations aboutdose adjustments, whether it is
talking to providers about sideeffects we really play a pivotal
role.
Speaker 1 (35:48):
Yeah, absolutely, that's great.
You know, I always taught mystudents when I was in academia
we have to be sleuths and I'vementioned that before on the
podcast, my favorite team, oneof my favorite TV shows of all
time is Murder.
She Wrote, and I love just howinquisitive she is and how JB
Fletcher always asks thequestions, and so I used to
always tell them you got to belike a JB Fletcher, you have to
(36:08):
ask the questions, write downthe information, put the pieces
of the puzzle together, and Ithink that is exactly what
you're saying with thesepatients as well.
So, rather than initiallyjumping to conclusions, or oh,
it's a, it's an opioidprescription.
It's definitely a red flag.
What are they diverting it?
You know, whatever it's askingthe questions trying to
understand, you may not realizethat they've just went through a
(36:30):
cancer diagnosis, you may notrealize that they're undergoing
some other type of treatment, or, or you know, surgery or
something.
So, so, yeah, I think it'sreally important that we're
asking the right questions andthen making an informed decision
as that provider for them.
So, yeah, such great stuff,lauren.
Thank you so much.
This was very, very helpful andjust kind of reminding us all
(36:53):
about pain management and how itis complex, but yet it's not
that complex, it's doable, rightLike.
It's something that we shouldall have a hand in and we should
all be doing so well.
Thanks again.
Super appreciate you spendingtime out of your busy schedule.
So thank you.
Speaker 2 (37:09):
Yes, thank you for having me.
I appreciate it.
Speaker 1 (37:11):
Absolutely.
If you're a CE plan subscriber,be sure to claim your CE credit
for this episode of GameChangers by logging in at
CEimpactcom.
And, as always, have a greatweek and keep learning.
I can't wait to dig intoanother game-changing topic with
you all next week.
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