Pharmacist educational interventions for cancer pain management: a systematic review and meta-analysis

Impact of pharmacist-delivered interventions on pain-related outcomes: An umbrella review of systematic reviews and meta-analyses

INTRODUCTION

Pain is a significant healthcare challenge, impacting millions worldwide. Pharmacists have increasingly taken on expanded roles in managing pain, particularly in primary and ambulatory care contexts. This umbrella review aims to systematically evaluate evidence from published systematic reviews that explore the impact of pharmacist-delivered interventions on clinical, humanistic, and economic outcomes related to pain.

METHODS

A systematic search was conducted across six electronic databases, including Ovid Embase, MEDLINE, CINAHL, Scopus, CENTRAL, APA PsycINFO, and DARE, from inception until June 2023. Prior to inclusion, two independent reviewers assessed study titles and abstracts. Following inclusion, an assessment of the methodological quality of the included studies was conducted. AMSTAR 2 was used to evaluate the methodological quality of the included SRs.

RESULTS

From 2055 retrieved titles, 11 systematic reviews were included, with 5 out of 11 being meta-analyses. These SRs encompassed diverse pharmacist-led interventions such as education, medication reviews, and multi-component strategies targeting various facets of pain management. These findings showed favorable clinical outcomes, including reduced pain intensity, improved medication management, enhanced overall physical and mental well-being, and reduced hospitalization durations. Significant pain intensity reductions were found due to pharmacists' interventions, with standardized mean differences (SMDs) ranging from -0.76 to -0.22 across different studies and subgroups. Physical functioning improvements were observed, with SMDs ranging from -0.38 to 1.03. Positive humanistic outcomes were also reported, such as increased healthcare provider confidence, patient satisfaction, and quality of life (QoL). QoL improvements were reported, with SMDs ranging from 0.29 to 1.03. Three systematic reviews examined pharmacist interventions' impact on pain-related economic outcomes, highlighting varying cost implications and the need for robust research methodologies to capture costs and benefits.

CONCLUSION

This umbrella review highlights the effectiveness of pharmacist-delivered interventions in improving clinical, humanistic, and economic outcomes related to pain management. Existing evidence emphasises on the need to integrate pharamacists into multi-disciplinary pain management teams. Further research is needed to investigate innovative care models, such as pharmacist-independent prescribing initiatives within collaborative pain management clinics.

Current practices, gaps, and opportunities on the role of clinical pharmacists in cancer pain management: Perspectives from Nepal

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Clinical and economic impact of clinical oncology pharmacy in cancer patients receiving injectable anticancer treatments: a systematic review

PURPOSE

Clinical pharmacy can reduce drug-related iatrogenesis by improving the management of adverse effects of drugs, limiting drug-drug interactions, and improving patient adherence. Given the vulnerability of cancer patients and the toxicity of injectable anticancer drugs, clinical pharmacy service (CPS) could provide a significant clinical benefit in cancer care. This review aims to synthesize existing evidence on clinical pharmacy's impact on patients treated with intravenous anticancer drugs.

METHODS

A comprehensive search was performed in the PubMed/Medline database from January 2000 to December 2021, associating the keywords: clinical pharmacy, pharmaceutical care, pharmacist, oncology, and chemotherapy. To be eligible for inclusion, studies have to report clinical pharmaceutical services for patients treated with intravenous chemotherapy with a clinical and/or economic impact.

RESULTS

Forty-one studies met the selection criteria. Various CPS were reported: medication reconciliation, medication review, and pharmaceutical interview with patient. There was a lack of randomized study (n = 3; 7.3%). In one randomized controlled trial, pharmaceutical intervention significantly improved quality of life of patients receiving pharmaceutical care during injectable anticancer drugs courses. Economical results appear to show positive impact of clinical pharmacy with cost savings reported from 3112.87$ to 249 844€. Although most studies were non-comparative, they highlighted that clinical pharmacy tend to limit chemotherapy side effects and drug-related problems, improve quality of life and satisfaction of patients and healthcare professional, and a positive economic impact.

CONCLUSION

Clinical pharmacy can reduce adverse drug events in cancer patients. More robust and economic evaluations are still required to support its development in everyday practice.

Pharmacists' Knowledge and Intention to Provide Palliative Care Services in Saudi Arabia: Using the Theory of Planned Behaviour

Providing palliative care to patients with life-threatening illnesses requires multidisciplinary efforts from different healthcare providers. Identifying the attitude, knowledge, and intentions of pharmacists to provide this service in Saudi Arabia is essential. Therefore, this study aimed to identify the palliative care knowledge, intentions, attitudes, subjective norms, and perceived behavioural control of pharmacists and what factors predict their intentions. Cross-sectional questionnaires based on the theory of planned behaviour were distributed to pharmacists in hospitals and community pharmacies. They included items that measured palliative care knowledge, attitudes, intentions, subjective norms, and the perceived behavioural control of pharmacists and identified other sociodemographic and pharmacy-practice-related items. In total, 131 pharmacists completed the questionnaires, showing an average score on palliative knowledge (8.82 ± 1.96; range: 1-14), strong intentions (5.84 ± 1.41; range: 1-7), positive attitudes (6.10 ± 1.47; range: 1-7), positive subjective norms (5.31 ± 1.32; range: 1-7), and positive perceived behavioural control (5.04 ± 1.21; range: 1-7). Having completed a pharmacy residency program, working longer hours per week, having a more positive attitude, and perceived stronger subjective norms were significantly associated with a strong intention to provide palliative care services. Therefore, enabling and motivating pharmacists to complete pharmacy residency programs and improve their attitudes could increase their intentions to provide these services.

Moderating effects of humanistic care and socioeconomic status on the relationship among pain intensity, psychological factors, and psychological function in adults with cancer pain from a province of China: A cross-sectional study

Objective

The objective of this study is to explore whether humanistic care practiced by clinical pharmacists and socioeconomic status moderate the associations among pain intensity, psychological factors (catastrophizing and resilience), and psychological function (depression and anxiety) in cancer patients with low levels of education and income in the Shanxi province in the Northwest of China.

Methods

Our sample comprised 123 adult inpatients with cancer pain. Demographic variables were obtained from the Hospital Information System of The Second Hospital of Shanxi Medical University. Pain intensity, psychological factors, and psychological functions were evaluated with four scales, and humanistic care was practiced with a part of the patients by clinical pharmacists. First, univariate analyses were conducted, followed by moderating effect models.

Results

The incidence of depression and anxiety in patients with cancer pain in our sample were 48.78 and 41.46%, respectively. Low levels of psychological resilience (63.37, SD 21.74) were in this study. Pain intensity was significantly associated with humanistic care and anxiety. Humanistic care practiced by clinical pharmacists moderated not only the association between resilience and pain intensity but also the association between pain intensity and anxiety. Education levels moderated the relationship between pain intensity and the psychological factors of catastrophizing and resilience. Income levels moderated the association between resilience and anxiety.

Conclusion

Humanistic care is essential in moderating the association among pain intensity, psychological factors, and psychological functions in Chinese cancer patients, especially those from lower-level counties and rural areas. Furthermore, socioeconomic statuses, such as education level and income, cannot easily change quickly. Still, proper humanistic care can relieve pain more effectively, reminding us that medical staff should implement effective personalized interventions to reduce patients' pain intensity.

A nationwide study on consumption of opioid analgesics in Iran from 2000 to 2018

BACKGROUND

Opioid analgesics play a unique role in pain management. National opioid consumption studies could provide indirect evidence of pain management in a country. National, regional, and global opioid consumption have been studied in other countries so far; however, conducting a focused study to illuminate the consumption of opioid analgesics over the past decades in Iran seemed necessary.

AIM

The main objective of this study was to determine the consumption of opioid analgesics and explore the trend of their use during 19 years in Iran.

METHOD

Iran pharmaceutical wholesale data were used to extract the annual consumption figures of the opioid analgesics in group N02A of the World Health Organization (WHO) Anatomical Therapeutic Chemical classification and were available in Iran (morphine, fentanyl, pethidine, and oxycodone as strong opioids and, tramadol and pentazocine as weak opioids), from 2000 to 2018. Using Defined Daily Dose (DDD) by WHO and Oral Morphine Equivalent (OMEQ), the amount of annual consumption was determined in DDD/1000 inhabitants/Day (DID) and OMEQ (mg)/1000 inhabitants/Day (OID).

RESULTS

Total opioid analgesic utilization based on DID and OID increased 31.12-fold (from 0.0196 to 0.61) and 21.06-fold (from 1.97 to 41.5 mg) over 19 years, respectively with a significant sharp increase from 2003 to 2006 (ß = 1.78 (DID), P value < 0.001). Medications that constituted 70% of annual opioid analgesics utilization were morphine in 2000, compared to tramadol in 2018. The annual weak and strong opioids share were 86.7% and 13.2% in 2018, respectively.

CONCLUSION

Despite considerable growth in the consumption of opioid analgesics in Iran over nearly two decades, the consumption amount remained low, which might signal sub-optimal pain management. On the other hand, misuse and abuse seem to be the main reason behind significant increases in the consumption of opioid analgesics with less controlled distribution.

Pharmacist Involvement in Cancer Pain Management: A Systematic Review and Meta-Analysis

This review aimed to critically evaluate the impact of pharmacist involvement in managing pain in cancer patients. Databases (including MEDLINE, Embase and CENTRAL) were searched with a broad search strategy for studies involving pharmacists and cancer pain management until February 10, 2021. The quality of studies and evidence were assessed using standardized tools and GRADE, respectively. A random-effects model was used for meta-analysis. Sixty-four studies were included. Common interventions delivered by the pharmacists were medication review, patient education, adverse drug reactions (ADRs) detection and management, pharmacological recommendations (in dosing and pharmacotherapy choice), and pain assessment. A pooled analysis of 3 randomized control trials showed a significant reduction in pain intensity with a standardized mean difference (SMD) of 0.35 [95% confidence intervals (CI): -0.55, -0.16]. Pooled analyses from nonrandomized studies of interventions also showed significant results in reduction of ADRs with an odds ratio of 0.69 (95% CI: 0.61, 0.79) and improvement in quality of life with SMD of 0.80 (95% CI: 0.29, 1.32). Thus, pharmacists significantly improve the clinical outcomes of cancer patients related to pain. This indicates the involvement of pharmacists directly or in collaboration with healthcare professionals in the oncology team is highly beneficial for the patients. PERSPECTIVES: This systematic review presents a comprehensive evaluation of pharmacist involvement in cancer pain management. This shows the importance of direct involvement of the pharmacist or as an important member of the multidisciplinary oncology team.

Knowledge, attitudes, and practices toward cancer pain management amongst healthcare workers (physicians, pharmacists, and nurses): a cross-sectional study from first-tier cities in China

PURPOSE

China is currently one of the countries with the largest increased number of new cancer cases in the world, but cancer pain management (CPM) is still inadequate. This study uses a questionnaire to demonstrate the status and differences in knowledge, attitude and practice (KAP) of CPM among healthcare workers (HCWs) in developed regions of China, to find deficiencies and priorities for improvement, from which areas and advantages of the role of pharmacists and mobile devices can be explored.

METHODS

This study used data from a questionnaire on CPM from March to June 2019. The study population consisted of a total of 515 HCWs in four first-tier developed cities in China. The questionnaire has four major components, analysis of differences in KAP of different occupations through one-way analysis of variance (ANOVA).

RESULTS

Among the respondents, the physicians had the highest knowledge scores toward CPM, pharmacists had the lowest practice scores. Around half of the respondents indicated that their hospital or department have a pharmacist participating in CPM. Physicians and nurses were more likely to expect pharmacists to provide drug counseling. The HCWs interviewed most expect that the mobile-based pain management system can automatically screen and mark patients with pain.

CONCLUSION

From this study, it can be suggested that pharmacists and nurses in the CPM team should actively promote relevant knowledge. Besides, pharmacists should focus on improving practical ability such as increasing the frequency of pain assessment. Multidisciplinary collaboration and the introduction of mobile devices can improve and refine the CPM.

Pain self-management interventions for community-based patients with advanced cancer: a research programme including the IMPACCT RCT

Background

Each year in England and Wales, 150,000 people die from cancer, of whom 110,000 will suffer from cancer pain. Research highlights that cancer pain remains common, severe and undertreated, and may lead to hospital admissions.

Objective

To develop and evaluate pain self-management interventions for community-based patients with advanced cancer.

Design

A programme of mixed-methods intervention development work leading to a pragmatic multicentre randomised controlled trial of a multicomponent intervention for pain management compared with usual care, including an assessment of cost-effectiveness.

Participants

Patients, including those with metastatic solid cancer (histological, cytological or radiological evidence) and/or those receiving anti-cancer therapy with palliative intent, and health professionals involved in the delivery of community-based palliative care.

Setting

For the randomised controlled trial, patients were recruited from oncology outpatient clinics and were randomly allocated to intervention or control and followed up at home.

Interventions

The Supported Self-Management intervention comprised an educational component called Tackling Cancer Pain, and an eHealth component for routine pain assessment and monitoring called PainCheck.

Main outcome measures

The primary outcome was pain severity (measured using the Brief Pain Inventory). The secondary outcomes included pain interference (measured using the Brief Pain Inventory), participants’ pain knowledge and experience, and cost-effectiveness. We estimated costs and health-related quality-of-life outcomes using decision modelling and a separate within-trial economic analysis. We calculated incremental cost-effectiveness ratios per quality-adjusted life-year for the trial period.

Results

Work package 1 – We found barriers to and variation in the co-ordination of advanced cancer care by oncology and primary care professionals. We identified that the median time between referral to palliative care services and death for 42,758 patients in the UK was 48 days. We identified key components for self-management and developed and tested our Tackling Cancer Pain resource for acceptability. Work package 2 – Patients with advanced cancer and their health professionals recognised the benefits of an electronic system to monitor pain, but had reservations about how such a system might work in practice. We developed and tested a prototype PainCheck system. Work package 3 – We found that strong opioids were prescribed for 48% of patients in the last year of life at a median of 9 weeks before death. We delivered Medicines Use Reviews to patients, in which many medicines-related problems were identified. Work package 4 – A total of 161 oncology outpatients were randomised in our clinical trial, receiving either supported self-management (n = 80) or usual care (n = 81); their median survival from randomisation was 53 weeks. Primary and sensitivity analyses found no significant treatment differences for the primary outcome or for other secondary outcomes of pain severity or health-related quality of life. The literature-based decision modelling indicated that information and feedback interventions similar to the supported self-management intervention could be cost-effective. This model was not used to extrapolate the outcomes of the trial over a longer time horizon because the statistical analysis of the trial data found no difference between the trial arms in terms of the primary outcome measure (pain severity). The within-trial economic evaluation base-case analysis found that supported self-management reduced costs by £587 and yielded marginally higher quality-adjusted life-years (0.0018) than usual care. However, the difference in quality-adjusted life-years between the two trial arms was negligible and this was not in line with the decision model that had been developed. Our process evaluation found low fidelity of the interventions delivered by clinical professionals.

Limitations

In the randomised controlled trial, the low fidelity of the interventions and the challenge of the study design, which forced the usual-care arm to have earlier access to palliative care services, might explain the lack of observed benefit. Overall, 71% of participants returned outcome data at 6 or 12 weeks and so we used administrative data to estimate costs. Our decision model did not include the negative trial results from our randomised controlled trial and, therefore, may overestimate the likelihood of cost-effectiveness.

Conclusions

Our programme of research has revealed new insights into how patients with advanced cancer manage their pain and the challenges faced by health professionals in identifying those who need more help. Our clinical trial failed to show an added benefit of our interventions to enhance existing community palliative care support, although both the decision model and the economic evaluation of the trial indicated that supported self-management could result in lower health-care costs.

Future work

There is a need for further research to (1) understand and facilitate triggers that prompt earlier integration of palliative care and pain management within oncology services; (2) determine the optimal timing of technologies for self-management; and (3) examine prescriber and patient behaviour to achieve the earlier initiation and use of strong opioid treatment.

Trial registration

Current Controlled Trials ISRCTN18281271.

Funding

This project was funded by the National Institute for Health Research Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 15. See the NIHR Journals Library website for further project information.

Effectiveness of collaboration between oncology pharmacists and anaesthesiologists for inpatient cancer pain management: A pilot study in Taiwan

OBJECTIVE

To evaluate the effectiveness of the collaboration between oncology pharmacists and anaesthesiologists for improving pain control management in cancer patients.

METHODS

This retrospective case-control pilot study enrolled inpatients with active cancer and a pain score of >3 at least once per day for 3 consecutive days. The study group was selected from June 2018 to January 2019. Patients with the same inclusion criteria were selected between November 2017 and May 2018 to serve as the comparison group. The primary outcome was the percentage of patients that experienced pain relief within 7 days from initial pain attack.

RESULTS

A total of 71 and 77 patients were enrolled in the study and comparison groups. More patients in the study group experienced pain relief within 7 days from the index date (78.9% [56 of 71 patients] versus 72.7% [56 of 77 patients], respectively). The service increased the rate of intervention from attending physicians within 4 days from index date and quality of opioid management.

CONCLUSION

The collaboration between oncology pharmacists and anaesthesiologists for cancer pain management may be associated with an increase in the rate of pain relief in cancer patients with poor pain control.

Understanding the role of hospice pharmacists: a qualitative study

Background Pharmacists are important members of multidisciplinary teams but, despite surveys of provision, the role of the hospice pharmacist is not well described. Objective To explore the role of the hospice pharmacist and identify barriers and facilitators to the role. Setting Hospices offering in-patient services caring for adults towards the end of life in one geographical area of northern England. Method Pharmacists providing services to hospices were invited to take part in qualitative semi-structured interviews asking about experience, patient contact, team working and barriers and facilitators to the role. These were recorded verbatim and data were analysed thematically using framework analysis. Main outcome measure The hospice pharmacist’s perceptions of their role and barriers and facilitators to it. Results Fifteen pharmacists took part. Two themes and ten subthemes were identified focused on tasks and communication. Practise was varied and time limited the quantity and depth of services carried out but was often spent navigating complex drug supply routes. Participants found methods of communication suited to the hours they spent in the hospice although communication of data was a barrier to effective clinical service provision. Participants identified the need for appropriate training and standards of practice for hospice pharmacists would enable better use of their skills. Conclusion Barriers to the role of hospice pharmacist include time, access to role specific training, access to clinical information and complex medicines supply chains. The role would benefit from definition to ensure that hospices are able to use hospice pharmacists to their greatest potential.

A systematic review of community pharmacy initiatives to improve treatment of depression and pain: Focus on types of programs and patient-reported outcomes

INTRODUCTION

Depression and pain are common, disabling, mutually exacerbating conditions. Many patients living with these conditions present to community pharmacies on a regular schedule to purchase both prescribed and over-the-counter medications. Community-pharmacy based programs have been developed to improve depression and pain outcomes.

METHODS

The PRISMA guidelines were utilized to answer the following question: In patients with depression and/or pain, what is the effect of the existing community pharmacy programs on depression and/or pain outcomes. Queried databases included Pubmed, EMBASE, and PsychINFO. DistillerSR was used to organize the screening, abstraction, and review of data. All potential articles were evaluated by two authors, and conflicts were discussed to achieve resolution. In addition to primary outcomes, sources of potential bias and quality indicators were abstracted for every article.

RESULTS

Three thousand nine hundred and twenty articles were reviewed, and 13 studies met eligibility criteria (n = 7 for depression; n = 6 for pain). Most studies demonstrated improvement in measures of depression or pain. However, compared to usual care or other control conditions, most of the depression and pain-specific interventions did not provide additional symptomatic benefit. The community pharmacy-based interventions were superior for other outcomes including medication adherence, reducing stigma, improvement in self-efficacy, and improvement in general management of disease.

CONCLUSION

Community pharmacies may be uniquely positioned to deliver interventions that improve outcomes associated with successful depression and pain treatment outcomes. However, the benefits of published community pharmacy-based treatments for actually improving depression and pain severity has not yet been established. Innovative interventions and additional research may be needed to achieve clinical success for pharmacy interventions for depression and pain.

Use of Chronic Prescription Medications and Prevalence of Polypharmacy in Survivors of Childhood Cancer

BACKGROUND

As survivors of childhood cancer age, development of cancer treatment-related chronic health conditions often occur. This study aimed to describe the pattern of chronic prescription medication use and identify factors associated with polypharmacy among survivors of childhood cancer.

METHODS

This was a retrospective study conducted at the pediatric oncology long-term follow-up clinic in Hong Kong. Eligible subjects included survivors who were (1) diagnosed with cancer before 18 years old, (2) were at least 3 years post-cancer diagnosis and had completed treatment for at least 30 days, and (3) receiving long-term follow-up care at the study site between 2015 and 2018. Dispensing records of eligible survivors were reviewed to identify medications taken daily for ≥30 days or used on an "as needed" basis for ≥6 months cumulatively within the past 12-month period. Polypharmacy was defined as the concurrent use of ≥5 chronic medications. Multivariable log-binomial modeling was conducted to identify treatment and clinical factors associated with medication use pattern and polypharmacy.

RESULTS

This study included 625 survivors (mean current age = 17.9 years, standard deviation [SD] = 7.2 years) who were 9.2 [5.2] years post-treatment. Approximately one-third (n = 219, 35.0%) of survivors were prescribed at least one chronic medication. Frequently prescribed medication classes include systemic antihistamines (26.5%), sex hormones (19.2%), and thyroid replacement therapy (16.0%). Overall prevalence of polypharmacy was 5.3% (n = 33). A higher rate of polypharmacy was found in survivors of CNS tumors (13.6%) than in survivors of hematological malignancies (4.3%) and other solid tumors (5.3%) (P = .0051). Higher medication burden was also observed in survivors who had undergone cranial radiation (RR = 6.31; 95% CI = 2.75-14.49) or hematopoietic stem-cell transplantation (HSCT) (RR = 3.53; 95% CI = 1.59-7.83).

CONCLUSION

Although polypharmacy was observed in a minority of included survivors of childhood cancer, chronic medication use was common. Special attention should be paid to survivors of CNS tumors and survivors who have undergone HSCT or cranial radiation. These individuals should be monitored closely for drug-drug interactions and adverse health outcomes that may result from multiple chronic medications, particularly during hospitalization in an acute care setting.

Evaluation of pharmacists' interventions on drug-related problems and drug costs in patients with cancer pain

BACKGROUND

Drug-related problems (DRPs) prevent patients from fully benefiting from drug treatment. Unrelieved pain in patients with cancer is still widespread. Pharmacists can play a role in closely monitoring cancer patients, pain control maintenance, and patient consultation.

OBJECTIVE

To evaluate the clinical effects and changes in drug costs of pharmacists' interventions on patients with DRPs related to cancer pain.

SETTING

An academic teaching hospital in Shanghai, China.

METHODS

Patients with cancer pain admitted to Shanghai Tongren Hospital from October 2018 to February 2019 were randomized into the intervention and control groups. The Pharmaceutical Care Network Europe classification V8.02 was used to categorize DRPs treated with analgesics. Patients' pain relief, the occurrence of adverse drug reactions, and drug cost-saving through the resolution of DRPs were evaluated.

MAIN OUTCOME MEASURE

Problems and causes of drug-related problems, interventions proposed, and outcome of pharmacy recommendations.

RESULTS

A total of 172 patients were enrolled and randomized into the intervention group (n = 86) and the control group (n = 86). The pharmacist detected 66 DRPs in 48 patients (55.8%) of the intervention group, an average of 0.8 DRPs per patient. A total of 149 interventions were proposed by the pharmacist. Compared to the control group, the drug intervention produced more pain relief on the third day of analgesic treatment. In the intervention group, a total of 33 DRP interventions resulted in cost changes, saving a drug cost of $489.90, averaging $11.94 per intervention.

CONCLUSION

Our study suggests that pharmacy service in patients with cancer pain can resolve drug-related problems and reduce drug costs.

Brief intervention medication therapy management: Establishment of an opioid misuse intervention model delivered in a community pharmacy

PURPOSE

Medication expertise and close patient contact position community pharmacists to make significant contributions to combatting the opioid epidemic. This position facilitated the development and initial implementation of the Brief Intervention Medication Therapy Management (BIMTM) model to detect and address patient opioid misuse. BIMTM is an intervention consisting of 9 sessions. One medication management session is delivered by a pharmacist in a community pharmacy setting, and the remaining sessions are delivered telephonically by a patient navigator to follow up with goals established with the pharmacist and address concomitant health concerns that increase risk for misuse.

METHODS

We employed the Consolidated Framework for Implementation Research (CFIR) to summarize and present key findings from 4 distinct studies. CFIR domains addressed were (1) intervention characteristics, (2) outer setting, (3) inner setting, (4) process, and (5) characteristics of individuals. The study results show sequential development of evidence for BIMTM.

RESULTS

A multistate cross-sectional pharmacist survey (n = 739) demonstrated limited pharmacist training and/or resources to address misuse, suggesting the need for external intervention development. Our multistakeholder intervention planning project showed limitations of current evidence-based models of care and of intervention implementation, which resulted in construction of the BIMTM. A multisite cross-sectional screening survey of patients (n = 333) established an electronic misuse screening protocol within 4 community pharmacies and identified opioid misuse in 15% of screened patients; among those patients, 98% had concomitant health conditions that contribute to the risk of opioid misuse. Presentation of study results to pharmacy leaders produced commitment for intervention implementation and a partnership to develop a grant proposal supporting this action. Our small-scale randomized trial evinced success in recruitment and retention and BIMTM patient benefit. The small-scale randomized trial likewise showed high levels of satisfaction with BIMTM.

CONCLUSION

The establishment of BIMTM supports community pharmacist identification and intervention with patients engaged in misuse. Continued use of this research-based strategy may further empower pharmacists to address the opioid epidemic.

Cancer pain management and the roles of pharmacists in China

Pain management impacts cancer treatment and patients' quality of life. This commentary describes the current state of cancer pain management in China. Areas of focus include creating the Good Pain Management model wards at hospitals and exploring pharmacy pain management clinics for community-dwelling cancer patients.

Practice review: Evidence-based and effective management of pain in patients with advanced cancer

BACKGROUND

Pain of a moderate or severe intensity affects over half of patients with advanced cancer and remains undertreated in at least one-third of these patients.

AIM

The aim of this study was to provide a pragmatic overview of the evidence supporting the use of interventions in pain management in advanced cancer and to identify where encouraging preliminary results are demonstrated but further research is required.

DESIGN

A scoping review approach was used to examine the evidence supporting the use of guideline-recommended interventions in pain management practice.

DATA SOURCES

National or international guidelines were selected if they described pain management in adult cancer patients and were written within the last 5 years in English. The Cochrane Database of Systematic Reviews (January 2014 to January 2019) was searched for 'cancer' AND 'pain' in the title, abstract or keywords. A MEDLINE search was also made.

RESULTS

A strong opioid remains the drug of choice for treating moderate or severe pain. Bisphosphonates and radiotherapy are also effective for cancer-related bone pain. Optimal management requires a tailored approach, support for self-management and review of treatment outcomes. There is likely a role for non-pharmacological approaches. Paracetamol should not be used in patients taking a strong opioid to treat pain. Cannabis-based medicines are not recommended. Weak opioids, ketamine and lidocaine are indicated in specific situations only.

CONCLUSION

Interventions commonly recommended by guidelines are not always supported by a robust evidence base. Research is required to evaluate the efficacy of non-steroidal anti-inflammatory drugs, anti-convulsants, anti-depressants, corticosteroids, some invasive anaesthetic techniques, complementary therapies and transcutaneous electrical nerve stimulation.

Multidisciplinary intervention incorporating pharmacists in management of opioid-naïve patients with moderate to severe cancer pain

OBJECTIVE

This study aims to investigate the impact of intervention of multidisciplinary team incorporating pharmacists for management of opioid-naïve patients with moderate to severe cancer pain.

METHODS

A retrospective cohort study was conducted to compare pre- and post-multidisciplinary intervention groups in opioid-naïve patients with moderate to severe cancer pain. Primary outcome was the proportions of appropriate pain assessment and opioid titration. Secondary outcomes were pain intensity (PI), length of hospital stay, opioid escalation index percentage (OEI%) and incidences of opioid-related adverse events.

RESULTS

A total of 400 patients were included in the study (pre-intervention, n = 200; post-intervention, n = 200). Continuous improvement in pain assessment and titration was recorded after intervention. Though no substantial differences existed between groups in PI on the day of discharge, post-intervention group was associated with reduced length of hospital stay as well as decreased proportion of subjects with OEI% >5%. As for safety, significant decreases in constipation and vomiting were seen.

CONCLUSION

Findings suggest that interventions of multidisciplinary team incorporating pharmacists could improve cancer pain management for opioid-naïve patients. Pharmacists should be considered as an important member of a multidisciplinary team in good pain management.

A community pharmacist medicines optimisation service for patients with advanced cancer pain: a proof of concept study

Background Patients with advanced cancer commonly experience pain and it is least controlled in community settings. Community pharmacists in the UK already offer medicines optimisation consultations although not for this patient group. Objective To determine whether medicines consultations for patients with advanced cancer pain are feasible and acceptable. Setting Community-dwelling patients with advanced cancer pain were recruited from primary, secondary and tertiary care using purposive sampling in one UK city. Methods One face-to-face or two telephone delivered medicines optimisation consultations by pharmacists were tested. These were based on services currently delivered in UK community pharmacies. Feedback was obtained from patients and healthcare professionals involved to assess feasibility and acceptability. Main outcome measure Recruitment, acceptability and drug related problems. Results Twenty-three patients, (range 33-88 years) were recruited, 19 completed consultation(s) of whom 17 were receiving palliative care services. Five received face-to-face consultations and 14 by telephone during which 47 drug related problems were identified from 33 consultations (mean 2.5). Advice was provided for 34 drug related problems in 17 patients and referral to other healthcare professionals for 13 in 8 patients, 2 patients had none. Eleven patients returned questionnaires of which 8 (73%) would recommend the consultations to others. Conclusion The consultations were feasible as patients were recruited, retained, consultations delivered, and data collected. Patients found the 20-30 min intervention acceptable, found a self-perceived increase in medicines knowledge and most would recommend it to others. Community pharmacists were willing to carry out these services however they had confidence issues in accessing working knowledge. Most drug related problems were resolved by the pharmacists and even among patients receiving palliative care services there were still issues concerning analgesic management. Pharmacist-conducted medicines consultations demonstrate potential which now needs to be evaluated within a larger study in the future.