CPMP Certification Review

Certified Pain Management Pharmacist (CPMP) Review

A Review Guide for the Certified Pain Management Pharmacist (CPMP) Exam

Block 1: Foundations of Pain Management

A-C

  • AAPM: American Academy of Pain Medicine.
  • ACEI: Angiotensin-Converting Enzyme Inhibitor.
  • ACPA: American Chronic Pain Association.
  • ADL: Activities of Daily Living.
  • APAP: Acetaminophen.
  • APS: American Pain Society.
  • ASA: Acetylsalicylic Acid (Aspirin).
  • CBT: Cognitive Behavioral Therapy.
  • CDC: Centers for Disease Control and Prevention.
  • COX: Cyclooxygenase.

D-I

  • DEA: Drug Enforcement Administration.
  • DN: Diabetic Neuropathy.
  • ER: Extended-Release.
  • FDA: Food and Drug Administration.
  • GABA: Gamma-Aminobutyric Acid.
  • HHS: Department of Health and Human Services.
  • IASP: International Association for the Study of Pain.
  • ICD-10: International Classification of Diseases, 10th Revision.
  • IM: Intramuscular.
  • IR: Immediate-Release.

L-O

  • LBP: Low Back Pain.
  • Lidoderm: Lidocaine patch.
  • MAOI: Monoamine Oxidase Inhibitor.
  • MAT: Medication-Assisted Treatment.
  • MME: Morphine Milligram Equivalents.
  • MS: Multiple Sclerosis.
  • NMDA: N-methyl-D-aspartate.
  • NSAID: Nonsteroidal Anti-Inflammatory Drug.
  • OA: Osteoarthritis.
  • OUD: Opioid Use Disorder.

P-R

  • PCA: Patient-Controlled Analgesia.
  • PDMP: Prescription Drug Monitoring Program.
  • PHN: Postherpetic Neuralgia.
  • PMP: Pain Management Plan.
  • PO: Per Os (by mouth).
  • PRN: Pro Re Nata (as needed).
  • QALY: Quality-Adjusted Life Year.
  • RA: Rheumatoid Arthritis.
  • REMS: Risk Evaluation and Mitigation Strategy.
  • RSD: Reflex Sympathetic Dystrophy (now CRPS).

S-Z

  • SAMHSA: Substance Abuse and Mental Health Services Administration.
  • SNRI: Serotonin-Norepinephrine Reuptake Inhibitor.
  • SSRI: Selective Serotonin Reuptake Inhibitor.
  • SUD: Substance Use Disorder.
  • TCA: Tricyclic Antidepressant.
  • TENS: Transcutaneous Electrical Nerve Stimulation.
  • WHO: World Health Organization.
  • CRPS: Complex Regional Pain Syndrome.
  • CGRP: Calcitonin Gene-Related Peptide.
  • NRS: Numeric Rating Scale (for pain).

Defining Pain

  • The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage."
  • Pain is always a personal and subjective experience.
  • It is influenced by biological, psychological, and social factors.
  • A patient's report of pain is the most reliable indicator of its existence.
  • Pain serves a protective role, alerting us to potential harm.
  • Chronic pain, however, often loses this protective function and becomes a disease in itself.
  • A CPMP must respect the patient's subjective experience of pain.

The Biopsychosocial Model of Pain

  • This model recognizes that pain is a complex experience influenced by multiple factors.
  • Bio (Biological): The pathophysiology of the pain, genetics, and physical health.
  • Psycho (Psychological): Thoughts, emotions (like anxiety and depression), and coping behaviors.
  • Social: Social support, cultural factors, and socioeconomic status.
  • Effective pain management requires addressing all three domains.
  • Relying solely on a biomedical approach (i.e., just prescribing medication) is often ineffective for chronic pain.
  • A CPMP must practice within this holistic framework.

The Pharmacist's Role in Pain Management

  • Pharmacists are key members of the interdisciplinary pain management team.
  • They are the medication experts, responsible for designing, implementing, and monitoring safe and effective analgesic regimens.
  • They play a crucial role in patient education about the realistic goals of therapy.
  • They are leaders in preventing and managing the adverse effects of pain medications.
  • A key role is to screen for and address opioid-related risks, including misuse and addiction.
  • A CPMP has advanced training to serve as a primary provider of pain management services, often under a collaborative practice agreement.

The Goal of Pain Management

  • The goal of pain management is not necessarily to eliminate pain completely.
  • For chronic pain, a more realistic and functional goal is to improve the patient's quality of life and functional ability.
  • This involves a shared decision-making process to set realistic goals.
  • Goals should be SMART: Specific, Measurable, Achievable, Relevant, and Time-bound.
  • An example of a functional goal is "To be able to walk my dog for 15 minutes a day within the next month."
  • A CPMP helps patients to shift the focus from pain scores to functional improvement.

The Interdisciplinary Team

  • The best practice model for chronic pain management is an interdisciplinary team approach.
  • This team can include:
  • Physicians (e.g., pain specialists, primary care).
  • Pharmacists (CPMP).
  • Physical and Occupational Therapists.
  • Psychologists or other mental health providers.
  • Nurses and social workers.
  • This team approach allows for the simultaneous treatment of the biological, psychological, and social aspects of pain.
  • The CPMP is the medication expert on this team.

Block 2: Pain Pathophysiology & Assessment

Acute vs. Chronic Pain

  • Acute Pain: A normal, predictable physiological response to a noxious stimulus. It is time-limited and serves a protective purpose.
  • Chronic Pain: Pain that persists beyond the normal healing time, typically defined as lasting for more than 3 months.
  • Chronic pain often loses its protective function and becomes a disease state in itself.
  • The underlying mechanisms and the treatment approaches for acute and chronic pain are very different.
  • A CPMP must be an expert in this distinction.

Nociceptive Pain

  • Nociceptive pain is caused by the stimulation of pain receptors (nociceptors) in response to tissue injury.
  • It is the "normal" type of pain signaling.
  • Somatic Pain: Arises from injury to skin, muscle, bone, or connective tissue. It is typically well-localized and described as sharp or aching. (e.g., a bone fracture).
  • Visceral Pain: Arises from internal organs. It is often poorly localized and described as cramping or gnawing. (e.g., appendicitis).
  • Nociceptive pain generally responds well to traditional analgesics like NSAIDs and opioids.

Neuropathic Pain

  • Neuropathic pain is caused by a lesion or disease of the somatosensory nervous system.
  • It is "pathological" pain that results from nerve damage.
  • It is often described with characteristic terms like "burning," "tingling," "numbness," or "pins and needles."
  • Examples include diabetic neuropathy, postherpetic neuralgia, and sciatica.
  • Neuropathic pain does not respond well to NSAIDs and may respond only partially to opioids.
  • The first-line treatments are adjuvant analgesics like gabapentinoids and certain antidepressants.

Nociplastic Pain (Central Sensitization)

  • Nociplastic pain is a newer term for pain that arises from altered nociception despite no clear evidence of actual tissue damage or nerve damage.
  • It is thought to be caused by a sensitization of the central nervous system ("central sensitization").
  • The pain processing system becomes amplified, like a volume knob turned up too high.
  • Conditions like fibromyalgia, irritable bowel syndrome, and temporomandibular disorder are thought to be examples of nociplastic pain.
  • This type of pain responds best to centrally-acting agents and non-pharmacologic therapies.

The Pain Pathway

  • The process of pain signaling can be broken down into four steps.
  • 1. Transduction: The conversion of a noxious stimulus into an electrical signal by a nociceptor.
  • 2. Transmission: The propagation of this signal up the spinal cord to the brain.
  • 3. Perception: The subjective experience of pain in the brain.
  • 4. Modulation: The "descending" pathway, where the brain can send signals back down the spinal cord to inhibit pain transmission.
  • Different classes of analgesics work at different points in this pathway.
  • A CPMP understands this pathway to rationally select medications.

The Multidimensional Nature of Pain

  • A comprehensive pain assessment must be multidimensional.
  • It goes beyond just asking about pain intensity.
  • It should assess the impact of the pain on the patient's physical function, emotional well-being, and social roles.
  • It should also explore the patient's own beliefs and goals related to their pain.
  • This aligns with the biopsychosocial model of pain.
  • A CPMP must be skilled at conducting this type of comprehensive assessment.

The PQRSTU Mnemonic

  • This is a useful mnemonic for conducting a basic pain history.
  • Palliative/Provocative: What makes it better or worse?
  • Quality: What does it feel like? (e.g., sharp, burning, aching). This can provide clues to the pain type.
  • Radiation: Does the pain travel anywhere?
  • Severity: How bad is it on a scale of 0-10?
  • Timing: When did it start? Is it constant or intermittent?
  • U: How does it affect yoUr function and quality of life?

Pain Intensity Scales

  • These are tools used to quantify the patient's self-reported pain intensity.
  • Numeric Rating Scale (NRS): The most common tool. Asks the patient to rate their pain on a scale of 0 to 10.
  • Visual Analog Scale (VAS): A 10-cm line where the patient marks their pain level.
  • Wong-Baker FACES Pain Rating Scale: Uses a series of faces, from smiling to crying. It is useful for children and for adults with cognitive or communication difficulties.
  • It is important to remember that these scales only measure one dimension of the pain experience.

Assessing Function and Quality of Life

  • For chronic pain, assessing the impact on function is more important than the pain score.
  • This involves asking about the patient's ability to perform their Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs).
  • Validated tools can be used to assess this more formally.
  • The PEG scale is a simple 3-item tool that assesses Pain, Enjoyment of life, and General activity.
  • The Brief Pain Inventory (BPI) is a more comprehensive tool.

Assessing for Neuropathic Pain

  • Because the treatment for neuropathic pain is different, it is important to screen for it.
  • The quality of the pain (burning, tingling, etc.) is a key clue.
  • Validated screening tools can be used to increase the accuracy of the assessment.
  • The DN4 (Douleur Neuropathique 4) is a simple 4-item questionnaire.
  • The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) is another common tool.
  • A CPMP should be familiar with these screening tools.

Block 3: Non-Opioid Pharmacotherapy

Acetaminophen (APAP)

  • Mechanism: Central analgesic, not fully understood. It is not an anti-inflammatory.
  • Role: First-line agent for mild to moderate pain, especially musculoskeletal pain like osteoarthritis. It is also an effective antipyretic (fever reducer).
  • Dosing: The maximum recommended daily dose is now 3,000-3,250 mg/day for most adults to reduce the risk of liver injury.
  • Major Risk: Hepatotoxicity (liver damage) in overdose. This is the most important safety concern.
  • A key role for a CPMP is to counsel patients on the maximum daily dose and to screen for "hidden" sources of APAP in combination products.

Non-Selective NSAIDs

  • Mechanism: Inhibit both the COX-1 and COX-2 enzymes, which blocks the production of prostaglandins. This provides both analgesic and anti-inflammatory effects.
  • Examples: Ibuprofen, naproxen, diclofenac, ketorolac.
  • Role: Effective for mild to moderate pain, especially when inflammation is a key component (e.g., rheumatoid arthritis, gout).
  • They are a cornerstone of multimodal analgesia.

COX-2 Selective NSAIDs (Celecoxib)

  • Mechanism: Selectively inhibits the COX-2 enzyme.
  • The COX-1 enzyme is responsible for producing the prostaglandins that protect the stomach lining.
  • By sparing COX-1, celecoxib causes significantly less gastrointestinal toxicity (e.g., ulcers, bleeding) than non-selective NSAIDs.
  • Role: A good option for patients who need an NSAID but are at high risk for GI complications.
  • It should be avoided in patients with a sulfa allergy.

NSAID Risks: GI and Renal

  • GI Risk: NSAIDs can cause dyspepsia, ulcers, and serious GI bleeding. The risk is higher in older adults and those with a history of ulcers. Co-prescribing a proton pump inhibitor (PPI) can reduce this risk.
  • Renal Risk: NSAIDs can cause acute kidney injury by constricting the afferent arteriole of the glomerulus. The risk is highest in patients with underlying kidney disease, heart failure, or dehydration, and in those taking ACEIs/ARBs.
  • A CPMP must be an expert at assessing and mitigating these risks.

NSAID Risks: Cardiovascular

  • All NSAIDs (except for low-dose aspirin) carry a Black Box Warning for an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke.
  • The risk is highest with COX-2 selective agents and with higher doses and longer durations of use.
  • They should be used with extreme caution in patients with established cardiovascular disease.
  • Naproxen is thought to have the lowest cardiovascular risk among the non-selective agents.
  • This cardiovascular risk is a critical counseling point.

The Role of Adjuvant Analgesics

  • Adjuvant analgesics are medications whose primary indication is for a condition other than pain, but which have been found to be effective as analgesics in certain situations.
  • They are the first-line treatment for neuropathic pain.
  • The main classes are the antidepressants and the anticonvulsants.
  • A CPMP must be an expert in the use of these medications.

Antidepressants (SNRIs and TCAs)

  • These drugs are thought to work by enhancing the descending inhibitory pain pathway in the spinal cord.
  • SNRIs (e.g., duloxetine, venlafaxine): First-line agents for neuropathic pain. They have the best evidence base and are generally well-tolerated.
  • TCAs (e.g., amitriptyline, nortriptyline): Also very effective, but their use is limited by significant anticholinergic side effects. They are a major high-risk medication in older adults.
  • SSRIs are generally not effective for neuropathic pain.

Anticonvulsants (Gabapentinoids)

  • Gabapentin and Pregabalin: These drugs are first-line agents for neuropathic pain.
  • They work by binding to the alpha-2-delta subunit of calcium channels in the CNS, which reduces the release of excitatory neurotransmitters.
  • They are particularly effective for conditions like diabetic neuropathy and postherpetic neuralgia.
  • The dose must be started low and titrated up slowly to minimize side effects like dizziness and sedation.
  • The dose must be adjusted for renal dysfunction.
  • These drugs are now classified as controlled substances in some states due to a potential for misuse.

Topical Agents

  • Topical agents are a good option for localized neuropathic pain.
  • They have the advantage of minimal systemic absorption and fewer side effects.
  • Lidocaine 5% Patch (Lidoderm): First-line for postherpetic neuralgia.
  • Capsaicin Patch: Can be effective but often causes significant burning at the application site.
  • Compounded topical pain creams are widely used, but there is very little high-quality evidence to support their efficacy.

Other Adjuvant Analgesics

  • NMDA Antagonists (e.g., ketamine, methadone): Can be effective for complex, refractory neuropathic pain, but their use is limited to specialists.
  • Alpha-2 Adrenergic Agonists (e.g., clonidine): Can be used as an adjuvant.
  • A key principle of neuropathic pain management is that it often requires a trial-and-error approach to find the most effective agent or combination for an individual patient.
  • A CPMP is skilled at guiding this process.

Skeletal Muscle Relaxants

  • This is a diverse class of drugs used to treat muscle spasms.
  • Their use should be limited to short-term treatment of acute musculoskeletal conditions.
  • There is little evidence to support their long-term use for chronic pain.
  • Most of them work through sedation at the CNS level.
  • Agents like carisoprodol and cyclobenzaprine have significant anticholinergic effects and are on the Beers Criteria list.
  • Carisoprodol is a controlled substance due to its high potential for abuse.
  • A CPMP generally discourages the chronic use of these agents.

Tramadol

  • Tramadol has a dual mechanism of action.
  • It is a weak mu-opioid receptor agonist.
  • It also inhibits the reuptake of serotonin and norepinephrine, similar to an SNRI.
  • This dual mechanism makes it effective for both nociceptive and neuropathic pain.
  • It is a Schedule IV controlled substance.
  • A key risk is that it can lower the seizure threshold.
  • It can also cause serotonin syndrome when combined with other serotonergic drugs.

Tapentadol

  • Tapentadol also has a dual mechanism of action.
  • It is a mu-opioid receptor agonist.
  • It also inhibits the reuptake of norepinephrine.
  • It is a Schedule II controlled substance.
  • Like tramadol, it has efficacy for both nociceptive and neuropathic pain.
  • It has a lower risk of GI side effects compared to traditional opioids.

Medical Cannabis and Cannabinoids

  • This is a complex and rapidly evolving area.
  • The cannabis plant contains hundreds of cannabinoids; the two most well-known are THC and CBD.
  • There is good evidence for the use of cannabinoids for chronic neuropathic pain.
  • However, the legal status of cannabis varies by state, and it remains a Schedule I substance at the federal level.
  • A CPMP must be an expert on the specific laws in their state.
  • They must be able to provide evidence-based, non-judgmental counseling to patients about the potential benefits and risks.

Ketamine

  • Ketamine is an NMDA receptor antagonist.
  • At low, sub-anesthetic doses, it can be a powerful analgesic, especially for complex neuropathic and centralized pain states.
  • It is typically administered as an IV infusion in a specialized pain clinic.
  • An intranasal formulation (esketamine) is approved for treatment-resistant depression.
  • The use of ketamine for chronic pain is an advanced practice area.
  • A CPMP working in a specialized pain clinic would be an expert in the use of this medication.

Block 4: Opioid Pharmacotherapy & Risk Management

Mechanism of Action

  • Opioids produce their analgesic effects by binding to opioid receptors in the central and peripheral nervous systems.
  • The three main types of opioid receptors are mu, kappa, and delta.
  • The mu receptor is primarily responsible for the analgesic effects of most opioids.
  • It is also responsible for the major adverse effects, including respiratory depression and euphoria.
  • A CPMP must have a deep understanding of this basic pharmacology.

Opioid Classification

  • Opioids can be classified in several ways.
  • By Receptor Activity: Full agonists (e.g., morphine), partial agonists (e.g., buprenorphine), and antagonists (e.g., naloxone).
  • By Origin: Natural (e.g., morphine, codeine), semi-synthetic (e.g., hydrocodone, oxycodone), and synthetic (e.g., fentanyl, methadone).
  • Understanding these classifications is key to understanding the differences between agents.

Pharmacokinetics and Metabolism

  • A key role for the CPMP is to select an opioid based on its pharmacokinetic profile.
  • Codeine and Tramadol: These are pro-drugs that must be metabolized by the CYP2D6 enzyme to their active form. Patients who are "poor metabolizers" at this enzyme will get no analgesic effect.
  • Morphine: Has an active metabolite (M6G) that is cleared by the kidneys. It can accumulate in patients with renal failure, leading to toxicity.
  • Methadone: Has a very long and variable half-life, which makes it difficult to titrate and creates a high risk of overdose.

Short-Acting vs. Long-Acting Opioids

  • Short-Acting/Immediate-Release (IR): Used for acute pain or for breakthrough pain in chronic pain patients.
  • Long-Acting/Extended-Release (ER): Used to provide baseline, around-the-clock analgesia for patients with severe, continuous chronic pain.
  • ER/LA opioids should only be used in patients who are already opioid-tolerant.
  • They have a Black Box Warning about the risk of overdose if they are crushed or chewed.
  • The CDC guideline recommends against the routine use of ER/LA opioids for chronic pain.

Opioid-Induced Side Effects

  • Opioids cause a wide range of side effects.
  • Constipation: The most common side effect. Tolerance does not develop, so a bowel regimen is almost always needed.
  • Nausea and Sedation: Common at the start of therapy, but tolerance usually develops.
  • Respiratory Depression: The most serious and life-threatening adverse effect. The risk is highest when opioids are combined with other sedating drugs like benzodiazepines.
  • Opioid-Induced Hyperalgesia: A paradoxical state where chronic opioid use can actually increase a person's sensitivity to pain.
  • A CPMP is an expert in the prevention and management of all of these side effects.

The Concept of Equianalgesic Dosing

  • An equianalgesic dose is the dose of one opioid that is approximately equivalent in analgesic effect to a given dose of another opioid.
  • These dose conversions are essential when rotating a patient from one opioid to another.
  • All conversions are calculated relative to a standard, which is typically 10mg of IV morphine or 30mg of oral morphine.
  • A CPMP must be an expert at performing these calculations.

Equianalgesic Tables

  • Equianalgesic tables provide the conversion ratios for common opioids.
  • It is important to use a reliable, evidence-based table.
  • It is also critical to remember that these tables are only an estimate.
  • They are based on single-dose studies in opioid-naive patients and may not be accurate for patients on chronic therapy.
  • They should be used as a guide, not as an absolute rule.

The 5-Step Conversion Process

  • A systematic, 5-step process should be used for any opioid conversion.
  • 1. Assess the patient and determine the total daily dose of the current opioid.
  • 2. Use the equianalgesic table to calculate the equivalent dose of the new opioid.
  • 3. Reduce the new dose by 25-50% to account for incomplete cross-tolerance. This is a critical safety step.
  • 4. Develop a plan for the new opioid regimen, including a dose for breakthrough pain.
  • 5. Monitor the patient closely after the rotation and adjust the dose as needed.

Incomplete Cross-Tolerance

  • Incomplete cross-tolerance is the phenomenon where a patient who is tolerant to one opioid is not fully tolerant to another.
  • This is why it is essential to reduce the calculated equianalgesic dose when rotating opioids.
  • Failure to do so is a common cause of iatrogenic overdose.
  • The standard dose reduction is 25-50%. A larger reduction should be used for high-risk patients or when rotating to a high-potency opioid like methadone.

Morphine Milligram Equivalents (MME)

  • MME is a value that represents the potency of an opioid in comparison to morphine.
  • It is used as a standardized measure of the total opioid dose a patient is receiving per day.
  • The CDC guideline recommends using caution when prescribing >50 MME/day and avoiding >90 MME/day.
  • A CPMP must be able to calculate the total daily MME for any patient on opioids.
  • This is a key metric for assessing overdose risk.

The Opioid REMS

  • The FDA has required a Risk Evaluation and Mitigation Strategy (REMS) for all extended-release and long-acting (ER/LA) opioid analgesics.
  • The goal of the REMS is to ensure that the benefits of these drugs outweigh the risks.
  • A key part of the REMS is an education program for prescribers.
  • It also requires that a patient-friendly Medication Guide be dispensed with every prescription.
  • A CPMP must be knowledgeable about the requirements of the opioid REMS.

Prescription Drug Monitoring Programs (PDMPs)

  • PDMPs are state-level databases that track the dispensing of controlled substances.
  • They are a critical tool for identifying patients who may be misusing or diverting opioids.
  • Most states now mandate that prescribers and/or pharmacists check the PDMP before prescribing or dispensing an opioid.
  • A CPMP must be an expert user of their state's PDMP.
  • They must be able to interpret the PDMP report to identify red flags.

Urine Drug Testing (UDT)

  • UDT is another key tool for monitoring patients on chronic opioid therapy.
  • It is used to verify that the patient is taking their prescribed opioid.
  • It is also used to screen for the use of non-prescribed or illicit drugs.
  • The results of a UDT must be interpreted carefully.
  • A CPMP must understand the limitations of the test and the metabolic pathways of different opioids to avoid misinterpretation.

Risk Assessment Tools

  • Validated screening tools can be used to assess a patient's risk for opioid misuse or addiction before starting therapy.
  • The Opioid Risk Tool (ORT) is a brief, self-report screening tool for use in primary care.
  • The Screener and Opioid Assessment for Patients with Pain (SOAPP) is another commonly used tool.
  • These tools can help to stratify patients by risk and to guide the monitoring strategy.

Naloxone Co-Prescribing

  • Naloxone is an opioid antagonist that can rapidly reverse an opioid overdose.
  • The CDC guideline recommends co-prescribing naloxone to all patients who are at high risk for overdose.
  • This includes patients on high doses of opioids (>50 MME/day) or those who are also taking a benzodiazepine.
  • Many states now have statewide standing orders that allow pharmacists to dispense naloxone without a patient-specific prescription.
  • A CPMP is a strong advocate for and a leader in expanding access to this life-saving medication.

Block 5: Specific Pain Conditions & Patient Populations

Diabetic Peripheral Neuropathy (DPN)

  • DPN is a common complication of diabetes, causing nerve damage, typically in the feet and legs.
  • It often presents with a "stocking-glove" distribution of symptoms.
  • Symptoms include burning, tingling, numbness, and shooting pains.
  • The cornerstone of management is optimal glycemic control to prevent progression.
  • Pharmacotherapy is aimed at symptomatic relief.
  • A CPMP plays a key role in managing the complex pharmacotherapy for this condition.

Postherpetic Neuralgia (PHN)

  • PHN is a complication of shingles (herpes zoster).
  • It is defined as pain that persists for more than 90 days after the onset of the shingles rash.
  • The pain is often severe and debilitating, described as burning or stabbing.
  • The risk of PHN increases with age.
  • The most effective prevention strategy is vaccination against shingles.
  • A CPMP is an advocate for and provider of the shingles vaccine.

First-Line Pharmacotherapy for Neuropathic Pain

  • The first-line agents for most types of neuropathic pain fall into two main classes.
  • Gabapentinoids (gabapentin and pregabalin): Work by modulating calcium channels.
  • SNRIs (duloxetine, venlafaxine): Work by enhancing the descending inhibitory pain pathway.
  • Tricyclic antidepressants (TCAs) are also a first-line option but are used less frequently in older adults due to side effects.
  • The choice between these agents is based on the patient's comorbidities and the side effect profiles.

Second- and Third-Line Agents

  • Topical Lidocaine: A first-line option specifically for localized PHN.
  • Capsaicin Patch: Can be effective for localized pain but causes significant application site reactions.
  • Tramadol and Tapentadol: Can be considered as second-line agents due to their dual mechanism of action.
  • Strong Opioids: Generally considered third-line agents for neuropathic pain due to limited efficacy and significant risks.
  • A CPMP must be an expert at sequencing these therapies.

Counseling and Management

  • Patient education is critical for managing neuropathic pain.
  • It is important to set realistic expectations; complete pain relief is rare.
  • The goal is a 30-50% reduction in pain and an improvement in function.
  • All of the first-line agents require slow dose titration to minimize side effects.
  • A therapeutic trial of a medication may take several weeks at an optimal dose.
  • A CPMP is skilled at guiding patients through this titration and trial process.

Pathophysiology (Central Sensitization)

  • Fibromyalgia is a chronic condition characterized by widespread musculoskeletal pain.
  • It is now understood to be a disorder of central pain processing, or "nociplastic" pain.
  • The central nervous system becomes amplified and hypersensitive to both painful and non-painful stimuli.
  • There is no peripheral tissue damage or inflammation.
  • This pathophysiology explains why traditional analgesics like NSAIDs and opioids are ineffective.

Clinical Presentation

  • The hallmark symptom is widespread pain, often described as a constant, dull ache.
  • It is almost always accompanied by severe fatigue and unrefreshing sleep.
  • Cognitive symptoms, often called "fibro fog," are also common.
  • Many patients also have co-occurring conditions like depression, anxiety, and irritable bowel syndrome.
  • A CPMP must be able to recognize the classic symptom cluster of fibromyalgia.

Non-Pharmacologic Therapy: The Cornerstone

  • Non-pharmacologic therapy is the foundation of fibromyalgia management.
  • Patient Education: Helping the patient to understand that their pain is real but is due to a sensitized nervous system, not tissue damage.
  • Exercise: A graded exercise program, especially low-impact aerobic exercise, is the most effective treatment.
  • Cognitive Behavioral Therapy (CBT): Helps patients to change their thoughts and behaviors related to pain.
  • Sleep Hygiene: Essential for managing fatigue.
  • A CPMP must be a strong advocate for these non-drug approaches.

FDA-Approved Pharmacotherapy

  • There are three drugs that are FDA-approved for fibromyalgia.
  • All of these agents work on the central nervous system.
  • Pregabalin (Lyrica): A gabapentinoid.
  • Duloxetine (Cymbalta): An SNRI.
  • Milnacipran (Savella): Another SNRI.
  • The efficacy of these drugs is modest, providing about a 30% reduction in pain for about half of patients.
  • They are considered an adjunct to, not a replacement for, non-pharmacologic therapy.

Inappropriate Therapies

  • A key role for the CPMP is to help deprescribe inappropriate medications for fibromyalgia.
  • Opioids: Are not effective for fibromyalgia and may even worsen the pain through opioid-induced hyperalgesia. Their use should be strongly discouraged.
  • NSAIDs and Acetaminophen: Are generally not effective, as fibromyalgia is not an inflammatory condition.
  • Benzodiazepines: Should be avoided due to risks and their negative impact on sleep architecture.
  • Educating both patients and providers about these inappropriate therapies is a critical function.

Osteoarthritis (OA)

  • OA is a degenerative joint disease, the most common type of arthritis.
  • It is characterized by the breakdown of cartilage in the joints.
  • It is a leading cause of chronic pain and disability, especially in older adults.
  • The pain is nociceptive and often related to activity.
  • Non-pharmacologic therapy, including exercise and weight loss, is the cornerstone of management.

Pharmacotherapy for OA

  • The choice of medication is guided by a stepwise approach.
  • First-line: Topical NSAIDs for knee or hand OA, and oral acetaminophen.
  • Second-line: Oral NSAIDs, used at the lowest effective dose for the shortest duration.
  • Third-line: Tramadol, duloxetine.
  • Intra-articular corticosteroid injections can provide short-term relief.
  • Opioids are generally not recommended for chronic OA.
  • A CPMP helps to create a safe and effective multimodal regimen.

Acute Low Back Pain (LBP)

  • Acute LBP is defined as pain lasting for less than 4 weeks.
  • Most cases are non-specific and will resolve on their own.
  • The key is to encourage the patient to remain active. Bed rest is not recommended.
  • First-line pharmacotherapy is with non-pharmacologic measures and, if needed, NSAIDs.
  • Skeletal muscle relaxants may be used for a short course but cause sedation.
  • Opioids should be avoided.

Chronic Low Back Pain (LBP)

  • Chronic LBP is pain lasting for more than 12 weeks.
  • Non-pharmacologic therapies are the foundation of management.
  • This includes exercise, physical therapy, and cognitive behavioral therapy.
  • First-line pharmacotherapy is NSAIDs.
  • Second-line agents include duloxetine and tramadol.
  • Opioids are not a preferred therapy for chronic LBP due to a lack of evidence for long-term benefit and significant risks.
  • A CPMP is an expert at designing non-opioid regimens for chronic LBP.

Topical Analgesics

  • Topical agents are a key part of the multimodal approach for localized musculoskeletal pain.
  • They have the major advantage of minimal systemic absorption and fewer side effects.
  • Topical NSAIDs (e.g., diclofenac gel): A first-line option for OA of the knee and hand.
  • Topical Capsaicin: Can be effective but causes a burning sensation.
  • Topical Lidocaine: While approved for PHN, it is often used off-label for musculoskeletal pain.
  • A CPMP should be an expert on the evidence and proper use of these agents.

Tension-Type Headache

  • This is the most common type of primary headache.
  • It is typically described as a bilateral, "band-like" pressure.
  • The pain is usually mild to moderate.
  • Acute treatment is with simple analgesics like acetaminophen or NSAIDs.
  • Frequent use of acute medications can lead to medication-overuse headache.
  • For chronic tension-type headache, the first-line preventive treatment is amitriptyline.

Migraine Headache

  • A migraine is a disabling primary headache disorder.
  • It is typically unilateral, pulsating, and moderate to severe in intensity.
  • It is often accompanied by nausea, photophobia, and phonophobia.
  • About one-third of patients experience an aura before the headache.
  • A CPMP must be an expert in the acute and preventive treatment of migraine.

Acute Migraine Treatment (Abortive Therapy)

  • The goal is to treat the attack early to relieve pain and restore function.
  • First-line for mild/moderate attacks: NSAIDs.
  • First-line for moderate/severe attacks: Triptans (serotonin 1B/1D receptor agonists).
  • Newer options: CGRP antagonists ("gepants") and ditans.
  • Opioids and butalbital-containing products should be avoided.
  • A key counseling point is to avoid overuse of acute medications to prevent medication-overuse headache.

Preventive Migraine Treatment

  • Preventive therapy is considered for patients with frequent or disabling migraines.
  • Traditional oral options include beta-blockers (e.g., propranolol), antidepressants (e.g., amitriptyline, venlafaxine), and anticonvulsants (e.g., topiramate, valproic acid).
  • The choice is guided by the patient's comorbidities and the side effect profile.
  • It can take several months to see the full benefit of a preventive medication.

CGRP Antagonists for Prevention

  • The newest and most significant advance in migraine prevention is the development of monoclonal antibodies that target Calcitonin Gene-Related Peptide (CGRP).
  • These are highly effective and well-tolerated biologic agents.
  • They are given as a monthly or quarterly subcutaneous injection.
  • There are also oral CGRP antagonists ("gepants") that can be used for prevention.
  • These drugs are very expensive and often require a prior authorization.
  • A CPMP must be an expert on the use and place in therapy of these new agents.

Geriatric Patients

  • Pain is very common in older adults, but its management is complex.
  • Older adults are at a much higher risk for adverse drug events due to age-related pharmacokinetic and pharmacodynamic changes.
  • The principle of "start low, go slow" is essential.
  • NSAIDs should be used with extreme caution due to their renal, GI, and cardiovascular risks.
  • Opioids cause more sedation and constipation in older adults.
  • A multimodal, non-pharmacologic approach is preferred.
  • A CPMP is an expert in safe analgesic prescribing for this population.

Pediatric Patients

  • Pain assessment in children, especially pre-verbal infants, is a major challenge.
  • Dosing of analgesics in children is almost always weight-based.
  • Safe dosing requires careful calculation to avoid errors.
  • Codeine should not be used in children due to the risk of ultra-rapid metabolism, which can lead to a morphine overdose.
  • A CPMP should be familiar with the principles of pediatric pain management.

Pregnant Patients

  • Pain management during pregnancy is a delicate balance between treating the mother's pain and protecting the fetus.
  • Acetaminophen is generally considered the safest analgesic during pregnancy.
  • NSAIDs should be avoided, especially in the third trimester.
  • Opioids should be used cautiously for a short duration. Chronic use can lead to neonatal abstinence syndrome.
  • A CPMP can be a key resource for managing pain in this complex population.

Patients with Renal or Hepatic Impairment

  • The dosing of many analgesics must be adjusted in patients with kidney or liver disease.
  • NSAIDs should generally be avoided in patients with significant renal impairment.
  • Acetaminophen is the preferred analgesic for these patients, but the dose must be limited in severe liver disease.
  • Many opioids and adjuvant analgesics require dose adjustment for renal dysfunction.
  • Morphine has an active metabolite that can accumulate in renal failure. Hydromorphone or fentanyl are often preferred.

Patients with a History of Substance Use Disorder

  • Managing pain in patients with a history of or active SUD is a major challenge.
  • These patients have a right to effective pain management.
  • A multimodal, non-opioid approach should be maximized.
  • If opioids are necessary for acute pain, they should be prescribed for a short duration with a clear plan.
  • Collaboration with the patient's addiction treatment provider is essential.
  • For patients on MOUD (e.g., buprenorphine), special strategies are needed to manage acute pain.
  • A CPMP is an expert in navigating these complex clinical and ethical situations.

Block 6: Opioid Stewardship & Risk Management

History of the Opioid Crisis

  • The current crisis began in the late 1990s with a dramatic increase in the prescribing of opioid analgesics.
  • This was driven by a push to treat pain as the "fifth vital sign" and by aggressive marketing from pharmaceutical companies.
  • This first wave led to a rise in addiction and overdose deaths from prescription opioids.
  • A second wave began around 2010 with a rise in deaths from heroin.
  • The third and current wave, which began around 2013, is driven by illicitly manufactured synthetic opioids, primarily fentanyl.
  • A CPMP must understand this history.

The CDC Guideline for Prescribing Opioids for Chronic Pain

  • In 2016, the CDC published a landmark guideline to promote safer opioid prescribing.
  • It emphasizes that non-opioid therapies are preferred for chronic pain.
  • When opioids are used, it recommends starting with the lowest effective dose of an immediate-release formulation.
  • It provides specific recommendations on dose thresholds (use caution at >50 MME/day, avoid >90 MME/day).
  • It also emphasizes the importance of risk mitigation strategies like PDMP checks and UDT.
  • A CPMP is an expert on implementing this guideline.

Opioid Stewardship

  • Opioid stewardship is a coordinated set of interventions designed to improve, monitor, and evaluate the use of opioids.
  • It is a key strategy for both improving patient safety and combating the opioid crisis.
  • The pharmacist is a key leader of the opioid stewardship program in a hospital or health system.
  • The program focuses on promoting safe prescribing, monitoring for high-risk use, and providing education.
  • A CPMP is often the person who leads these stewardship initiatives.

Harm Reduction

  • Harm reduction is a pragmatic public health approach that aims to reduce the negative consequences of substance use.
  • It is a key part of a comprehensive response to the overdose crisis.
  • Key harm reduction services include:
  • Naloxone Access: Dispensing the opioid overdose reversal drug.
  • Syringe Service Programs (SSPs): Providing sterile syringes to prevent the spread of HIV and Hepatitis C.
  • Fentanyl Test Strips: Allowing people to test their drugs for the presence of deadly fentanyl.
  • A CPMP should be a strong advocate for these life-saving services.

Medication-Assisted Treatment (MAT) / MOUD

  • The evidence-based standard of care for Opioid Use Disorder (OUD) is Medications for OUD (MOUD), formerly known as MAT.
  • The three FDA-approved medications are methadone, buprenorphine, and naltrexone.
  • A key public health goal is to expand access to MOUD.
  • Pharmacists are playing an increasingly important role in this, including initiating buprenorphine in some states.
  • A CPMP is an expert on the pharmacology and clinical use of these medications.

Universal Precautions for Opioids

  • The concept of "universal precautions" for opioids is an approach that applies a standard set of risk mitigation strategies to all patients on chronic opioid therapy.
  • This is because it is difficult to predict which individual patient will develop a problem.
  • This approach moves away from just trying to identify "problem patients."
  • The core components are a thorough assessment, a treatment agreement, regular monitoring, and documentation.

Risk Assessment Tools

  • Validated screening tools can be used to assess a patient's risk for opioid misuse or addiction before starting therapy.
  • The Opioid Risk Tool (ORT) is a brief, self-report screening tool for use in primary care.
  • The Screener and Opioid Assessment for Patients with Pain (SOAPP) is another commonly used tool.
  • These tools can help to stratify patients by risk (low, moderate, high) and to guide the intensity of the monitoring strategy.

Prescription Drug Monitoring Programs (PDMPs)

  • PDMPs are state-level databases that track the dispensing of controlled substances.
  • They are a critical tool for identifying patients who may be receiving prescriptions from multiple providers ("doctor shopping") or filling at multiple pharmacies.
  • Most states now mandate that prescribers and/or pharmacists check the PDMP before prescribing or dispensing an opioid.
  • A CPMP must be an expert user of their state's PDMP.

Urine Drug Testing (UDT)

  • UDT is another key tool for monitoring patients on chronic opioid therapy.
  • It is used to verify that the patient is taking their prescribed opioid (an expected positive result).
  • It is also used to screen for the use of non-prescribed or illicit drugs (an unexpected positive result).
  • The results of a UDT must be interpreted carefully.
  • A CPMP must understand the limitations of the test and the metabolic pathways of different opioids to avoid misinterpretation.

Patient-Provider Agreements (Pain Contracts)

  • A patient-provider agreement is a formal document that outlines the expectations and responsibilities of both the patient and the provider.
  • It is a tool for promoting communication and informed consent.
  • It typically includes the goals of therapy, the plan for monitoring, and the policies on issues like early refills and lost prescriptions.
  • The agreement should be used to facilitate a conversation, not just as a contract to be signed.
  • A CPMP can help to develop and implement these agreements.

Rationale for Tapering

  • Opioid tapering is the process of gradually reducing a patient's long-term opioid dose.
  • It should be considered for any patient on chronic opioid therapy who is not having a clinically meaningful improvement in pain and function.
  • It is also indicated for patients who are on high doses (>50 MME/day) or who are experiencing adverse effects.
  • The goal is to reduce the risks of long-term opioid therapy while minimizing withdrawal symptoms.
  • A CPMP is an expert in managing this complex and challenging process.

The Shared Decision-Making Conversation

  • The decision to taper must be made in collaboration with the patient.
  • Many patients are very fearful of a dose reduction.
  • The conversation must be empathetic and non-judgmental.
  • It should focus on the shared goal of improving the patient's safety and quality of life, not on simply reducing a number.
  • The pharmacist can use motivational interviewing techniques to help the patient explore their own reasons for wanting to taper.

Developing a Tapering Plan

  • The tapering plan must be individualized.
  • There is no one-size-fits-all approach.
  • A general rule of thumb is to reduce the total daily dose by about 10% every 1-4 weeks.
  • The taper should be slower for patients who have been on opioids for a long time or who are very anxious.
  • The plan must be clear and provided to the patient in writing.
  • A CPMP is an expert at creating these patient-specific tapering schedules.

Managing Withdrawal Symptoms

  • A slow taper is designed to minimize withdrawal symptoms, but some may still occur.
  • Common symptoms include anxiety, insomnia, nausea, and muscle aches.
  • Adjunctive medications can be used to help manage these symptoms.
  • Clonidine is often used to treat the autonomic symptoms of withdrawal.
  • Other comfort medications can be used for nausea, diarrhea, and insomnia.
  • The CPMP can recommend and manage these adjunctive medications.

Monitoring and Support

  • Close follow-up and support are essential for a successful taper.
  • This involves regular check-ins with the patient, either in person or by phone.
  • The pharmacist should monitor for withdrawal symptoms and assess the patient's pain and function.
  • It is important to provide positive reinforcement and to celebrate small successes.
  • The plan may need to be adjusted based on the patient's response. The patient should be empowered to have control over the pace of the taper.

Defining OUD

  • OUD is a chronic, relapsing brain disease characterized by a problematic pattern of opioid use leading to clinically significant impairment or distress.
  • It is a medical diagnosis, defined by criteria in the DSM-5.
  • It is not a moral failing.
  • A key part of the CPMP's role is to reduce the stigma associated with OUD.
  • This includes using person-first, non-stigmatizing language.

Screening and Diagnosis

  • The pharmacist can play a key role in screening for OUD.
  • This involves being alert to "red flags" in the pharmacy, such as patients frequently requesting early refills or appearing sedated.
  • Validated screening tools can also be used.
  • A formal diagnosis is made by a qualified provider based on the 11 criteria in the DSM-5.
  • The pharmacist's role is to screen and refer for diagnosis.

Medications for OUD (MOUD)

  • MOUD is the evidence-based standard of care for OUD. It significantly reduces the risk of overdose death.
  • Methadone: A long-acting full opioid agonist. Can only be dispensed by a federally-regulated Opioid Treatment Program (OTP).
  • Buprenorphine: A partial opioid agonist. Can be prescribed from an office setting and dispensed by a community pharmacy. Often co-formulated with naloxone (Suboxone).
  • Naltrexone: An opioid antagonist. Available as a long-acting injection (Vivitrol). The patient must be fully detoxed from opioids before starting.
  • A CPMP is an expert on these life-saving medications.

The Pharmacist's Role in Buprenorphine Therapy

  • Pharmacists are a key partner in expanding access to buprenorphine.
  • They are responsible for dispensing the medication and providing patient education.
  • They play a crucial role in the induction process, ensuring the patient is in a state of mild withdrawal before the first dose.
  • They help to monitor for adherence and side effects.
  • In some states, pharmacists now have the authority to initiate buprenorphine therapy under a CPA.

Harm Reduction

  • Harm reduction is a pragmatic approach that aims to reduce the negative consequences of substance use.
  • It is a key part of a comprehensive approach to OUD.
  • Key harm reduction services that can be provided by a pharmacy include:
  • Naloxone Access: Dispensing the opioid overdose reversal drug.
  • Syringe Service Programs (SSPs): Providing sterile syringes to prevent the spread of HIV and Hepatitis C.
  • Fentanyl Test Strips: Allowing people to test their drugs for the presence of deadly fentanyl.
  • A CPMP is a strong advocate for removing barriers to these services.

The Importance of Non-Drug Therapies

  • For chronic pain, non-pharmacologic therapies are the foundation of management.
  • They are often more effective than medications in the long term and have fewer side effects.
  • A multimodal approach that combines these therapies with medication is the standard of care.
  • A CPMP must be an expert on these non-drug approaches and be able to refer patients to the appropriate providers.
  • They are a key part of a holistic, biopsychosocial treatment plan.

Physical and Rehabilitative Therapies

  • Physical Therapy (PT): A cornerstone of chronic pain management. It focuses on improving movement and function through a tailored exercise program.
  • Occupational Therapy (OT): Helps patients to perform their activities of daily living.
  • Massage Therapy: Can be helpful for musculoskeletal pain.
  • Acupuncture: Has evidence for several types of chronic pain, including low back pain and migraine.
  • TENS (Transcutaneous Electrical Nerve Stimulation): Uses low-voltage electrical current to provide pain relief.

Psychological and Behavioral Therapies

  • These therapies are essential for addressing the "psycho" part of the biopsychosocial model.
  • Cognitive Behavioral Therapy (CBT): The most well-established psychological therapy for chronic pain. It helps patients to change their thoughts, emotions, and behaviors related to pain.
  • Acceptance and Commitment Therapy (ACT): A mindfulness-based therapy that helps patients to live a meaningful life despite their pain.
  • Biofeedback: A technique that teaches patients to control physiological functions like muscle tension.

Mind-Body Practices

  • These practices focus on the interaction between the brain, mind, body, and behavior.
  • Yoga and Tai Chi: Combine gentle movement, breathing, and meditation. Have good evidence for conditions like low back pain.
  • Mindfulness-Based Stress Reduction (MBSR): A formal program that teaches mindfulness meditation.
  • These practices can help to down-regulate the sensitized nervous system in chronic pain.

The Pharmacist's Role in Promoting Non-Drug Therapies

  • The CPMP is a key advocate for and educator about these non-drug approaches.
  • They can provide basic counseling on things like the importance of exercise and sleep hygiene.
  • They can also make formal referrals to other providers on the interdisciplinary team, such as physical therapists and psychologists.
  • This integrated approach is the key to successful chronic pain management.
  • It helps to move beyond a purely medication-focused model of care.

Block 7: Advanced Topics & Practice Management

Principles of Cancer Pain Management

  • Pain is one of the most common and feared symptoms in patients with cancer.
  • Effective pain management is a critical part of high-quality cancer care.
  • The WHO Analgesic Ladder provides a foundational framework for treating cancer pain.
  • Unlike chronic non-cancer pain, long-term opioid therapy is often appropriate and necessary for cancer-related pain.
  • The goal is to provide adequate analgesia to allow the patient to maintain their quality of life and function.
  • A CPMP working in oncology must be an expert in this area.

The WHO Analgesic Ladder

  • The ladder provides a stepwise approach to analgesic selection.
  • Step 1 (Mild Pain): Non-opioid analgesics (acetaminophen, NSAIDs) +/- adjuvants.
  • Step 2 (Mild to Moderate Pain): Weak opioids (e.g., codeine, tramadol) +/- non-opioids and adjuvants.
  • Step 3 (Moderate to Severe Pain): Strong opioids (e.g., morphine, hydromorphone, fentanyl) +/- non-opioids and adjuvants.
  • The principle is to move up the ladder as the pain intensity increases.

Managing Breakthrough Pain

  • Patients on a long-acting opioid for baseline pain often experience episodes of "breakthrough" pain.
  • This requires the use of a short-acting, immediate-release opioid for rescue.
  • The rescue dose is typically calculated as 10-15% of the total 24-hour baseline opioid dose.
  • Rapid-onset transmucosal fentanyl products are approved specifically for breakthrough cancer pain in opioid-tolerant patients.
  • A CPMP is responsible for designing a safe and effective breakthrough pain regimen.

Adjuvant Analgesics in Cancer Pain

  • Adjuvant analgesics are essential for a multimodal approach to cancer pain.
  • Neuropathic Pain: Gabapentinoids and SNRIs are first-line.
  • Bone Pain: NSAIDs, corticosteroids, and bisphosphonates are effective.
  • Corticosteroids (e.g., dexamethasone): Very effective for pain caused by inflammation or nerve compression.
  • The CPMP is an expert at selecting the appropriate adjuvant based on the type of pain.

Pain Management in Cancer Survivors

  • As cancer treatments improve, there is a growing population of cancer survivors.
  • Many of these survivors are left with chronic pain as a result of their cancer or its treatment (e.g., chemotherapy-induced peripheral neuropathy).
  • The management of this chronic post-cancer pain is a major challenge.
  • The principles of chronic non-cancer pain management, with a focus on non-opioid and non-pharmacologic therapies, are often more appropriate for this population.
  • A CPMP must be able to tailor the treatment plan to the individual survivor's needs.

Principles of Palliative Care

  • Palliative care is specialized medical care for people with serious illnesses.
  • It is focused on providing relief from the symptoms and stress of the illness.
  • The goal is to improve quality of life for both the patient and the family.
  • It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.
  • Pain management is a core component of palliative care.

Goals of Care

  • In the palliative care setting, the goals of care often shift from prolonging life to maximizing comfort and quality of life.
  • This has a major impact on the benefit-risk assessment of pain medications.
  • The risk of long-term complications like addiction is less of a concern.
  • The primary goal is to provide adequate pain relief, even if it causes side effects like sedation.
  • A CPMP must be skilled at having these goals of care conversations.

Aggressive Symptom Management

  • Pain at the end of life can be severe and complex.
  • Aggressive, around-the-clock opioid therapy is often necessary.
  • There is no "ceiling dose" for opioids in this setting; the dose is titrated to the patient's pain, limited only by side effects.
  • Adjuvant analgesics are also used extensively.
  • The CPMP is an expert at designing these complex, aggressive analgesic regimens.

The Principle of Double Effect

  • This is a key ethical principle in end-of-life care.
  • It states that an action that has a good intention (relieving pain) is permissible even if it has a known, but unintended, bad effect (potentially hastening death through respiratory depression).
  • This principle provides the ethical justification for the use of high-dose opioids and sedatives to relieve suffering at the end of life.
  • A CPMP must understand this important ethical concept.

Deprescribing

  • In addition to prescribing symptom-focused medications, a key part of palliative care is deprescribing.
  • This is the process of stopping medications that are no longer providing a benefit or that are inconsistent with the goals of care.
  • Preventive medications with a long time-to-benefit (like statins) are often the first to be stopped.
  • The goal is to reduce the pill burden and the risk of side effects from non-essential medications.
  • A CPMP is a leader in this deprescribing process.

Pain Intensity Scales

  • Numeric Rating Scale (NRS): Patient rates pain on a 0-10 scale. Most common tool for quantifying pain intensity.
  • Visual Analog Scale (VAS): A 10-cm line where the patient marks their pain level.
  • Wong-Baker FACES Scale: Uses facial expressions to represent pain levels, useful for children or adults with communication barriers.
  • These scales are simple but only measure one dimension of pain.

Multidimensional Pain Assessment Tools

  • These tools assess the impact of pain on function and quality of life.
  • Brief Pain Inventory (BPI): Assesses pain severity and the degree to which pain interferes with daily activities.
  • PEG Scale: A simple 3-item scale assessing Pain, Enjoyment of life, and General activity. Excellent for tracking functional improvement in primary care.
  • McGill Pain Questionnaire (MPQ): A comprehensive tool that assesses the sensory, affective, and evaluative dimensions of pain.

Neuropathic Pain Screening Tools

  • Validated questionnaires used to help identify patients with a neuropathic pain component.
  • DN4 (Douleur Neuropathique 4): A simple 4-item tool with questions about pain quality and a physical examination component.
  • LANSS (Leeds Assessment of Neuropathic Symptoms and Signs): Another widely used screening tool.
  • A high score on one of these tools suggests that a neuropathic pain medication should be considered.

Opioid Risk Assessment Tools

  • Screening tools used to assess a patient's risk for developing opioid use disorder before starting chronic opioid therapy.
  • Opioid Risk Tool (ORT): A brief, self-report questionnaire for primary care.
  • SOAPP-R (Screener and Opioid Assessment for Patients with Pain-Revised): A longer, more detailed self-report tool.
  • These tools help to stratify patients into low, moderate, or high risk to guide the intensity of monitoring.

Monitoring Tools for Patients on Opioids

  • Tools used to monitor for aberrant drug-related behaviors in patients on chronic opioid therapy.
  • Pain Medication Questionnaire (PMQ): A self-report tool to screen for potential opioid misuse.
  • Current Opioid Misuse Measure (COMM): Another self-report tool to help identify if a patient is misusing their opioids.
  • The 4 A's: A simple framework for monitoring outcomes: Analgesia, Activity, Adverse effects, and Aberrant behaviors.
  • A CPMP uses these tools as part of the routine monitoring of their patients.

Creatinine Clearance (CrCl) - Cockcroft-Gault

  • The single most important calculation in pain management. Essential for the safe dosing of many analgesics, including gabapentinoids, tramadol, and certain opioids (e.g., morphine).

\( \text{CrCl (mL/min)} = \frac{(140 - \text{Age}) \times \text{Weight (kg)}}{72 \times \text{Serum Cr (mg/dL)}} \times (0.85 \text{ if female}) \)

Opioid Equianalgesic Conversion

  • The core calculation for safely rotating a patient from one opioid to another. This requires memorization of key conversion ratios and the application of a systematic, multi-step process.

Example: Oral Morphine 30mg = Oral Hydrocodone 30mg = Oral Oxycodone 20mg = IV Morphine 10mg = IV Hydromorphone 1.5mg

Morphine Milligram Equivalents (MME) Calculation

  • A standardized calculation used to determine the total opioid dose a patient is receiving per day, expressed in terms of its equivalence to oral morphine. It is a key metric for assessing overdose risk.

\( \text{Total MME/day} = \sum (\text{Strength per unit} \times \text{Units per day} \times \text{MME factor}) \)

Breakthrough Pain Dose Calculation

  • A calculation used to determine the appropriate dose for a short-acting, as-needed opioid for patients on a long-acting baseline regimen. The correct dose is essential for both safety and efficacy.

\( \text{Breakthrough Dose} = 10\% \text{ to } 15\% \text{ of the Total 24-hour Opioid Dose} \)

QTc Interval Correction (Bazett's Formula)

  • This calculation is important when managing pain with methadone or other drugs that can prolong the QT interval. The QTc corrects the measured QT interval for the patient's heart rate.

\( QTc = \frac{QT}{\sqrt{RR}} \) Where RR is the interval from one R-wave to the next in seconds.

The Collaborative Practice Agreement (CPA)

  • A CPA is a legal agreement between a pharmacist and a provider that allows the pharmacist to perform certain patient care functions.
  • For a pain specialist pharmacist, a CPA is essential for an advanced practice model.
  • The CPA may grant the pharmacist the authority to initiate, adjust, and discontinue pain medications according to the agreed-upon protocol.
  • It may also allow the pharmacist to order and interpret relevant lab tests.
  • A CPMP must be an expert on the specific CPA laws in their state.

Pharmacist-Led Pain Clinics

  • Under a CPA, a pharmacist can run their own pain management clinic.
  • This involves taking referrals from primary care providers.
  • The pharmacist conducts a comprehensive assessment, develops a treatment plan, and provides ongoing follow-up care.
  • This model has been shown to improve pain, function, and safety, while also reducing the burden on primary care.
  • A CPMP is the ideal professional to lead these clinics.

Billing for Services

  • A key part of a sustainable practice model is getting paid for the cognitive services the pharmacist provides.
  • This can be a challenge, but there are several potential pathways.
  • Pharmacists can bill for MTM services.
  • In some settings, pharmacists can bill "incident to" a physician under Medicare Part B.
  • Some states and health plans are also starting to recognize pharmacists as providers and allow them to bill directly.
  • A CPMP must be knowledgeable about the billing opportunities in their practice environment.

Interprofessional Communication

  • A collaborative practice is built on a foundation of strong interprofessional communication.
  • The CPMP must be able to communicate their recommendations to physicians in a clear, concise, and evidence-based manner.
  • They must also be an excellent collaborator with other members of the pain team, like physical therapists and psychologists.
  • This requires mutual trust and respect.

Demonstrating Value

  • To sustain and grow a collaborative practice, the CPMP must be able to demonstrate their value.
  • This requires tracking and reporting key outcomes.
  • Clinical Outcomes: Improvement in pain scores and functional measures.
  • Safety Outcomes: Reduction in total MME, reduction in the use of co-prescribed benzodiazepines.
  • Economic Outcomes: Reduction in ER visits or hospitalizations.
  • This data provides a powerful case for the value of a pharmacist-led pain management service.

Treat the Person, Not the Pain Score

  • A core concept is that the goal of pain management is to improve function and quality of life, not just to chase a pain score of zero.
  • This requires a holistic, biopsychosocial approach.
  • The treatment plan must be individualized to the patient's specific goals and values.
  • This patient-centered focus is the foundation of effective and ethical pain care.

A Multimodal Approach is Best

  • The most effective pain management plan is a multimodal one.
  • This involves combining multiple different strategies to attack the pain from different angles.
  • This includes the rational use of multiple medications (multimodal analgesia).
  • Crucially, it also involves integrating non-pharmacologic therapies like physical therapy and CBT.
  • A CPMP is an expert at designing and coordinating this multimodal approach.

Non-Opioids are the Foundation

  • For most types of chronic non-cancer pain, non-opioid medications and non-pharmacologic therapies are the foundation of treatment.
  • Opioids should not be considered a first-line or routine therapy.
  • The goal is to maximize the use of safer and often more effective non-opioid strategies first.
  • A CPMP is an expert in evidence-based, opioid-sparing pain management.

Safety First: The Principle of Universal Precautions

  • When opioids are used for chronic pain, a "universal precautions" approach to safety is essential.
  • This means that all patients on long-term opioids should be considered at risk for developing problems.
  • Therefore, a standard set of risk mitigation strategies (e.g., treatment agreements, PDMP checks, UDT) should be applied to all patients.
  • This proactive approach to safety is a core responsibility of a CPMP.

The Pharmacist as an Advocate and Educator

  • A CPMP is more than just a medication expert; they are a patient advocate and educator.
  • They advocate for patients to have access to comprehensive, interdisciplinary pain care.
  • They advocate for the safe and rational use of opioids in their health system and community.
  • They are key educators for patients, other healthcare providers, and the public.
  • This leadership and advocacy role is a key part of the professional identity of a Certified Pain Management Pharmacist.
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