Implementation and assessment of a pilot, community pharmacy-based, opioid pain medication management program.

OBJECTIVES: This study aimed to evaluate care gaps in risk- and harm-reduction strategies for patients prescribed opioids and to describe the implementation of a community pharmacy-based, pilot pain-management program. SETTING: The pilot program was established in a community pharmacy within an academic medical center. Patients enrolled were prescribed opioids for chronic pain by a rheumatology clinic. PRACTICE DESCRIPTION: The patients enrolled met 1 or more of the following criteria: they were prescribed more than 1 short-acting opioid; more than 90 morphine milligram equivalents/d; and more than 7 days' supply of medications for acute pain, including high-risk medication combinations. Comprehensive pain-medication assessments and pharmacist interventions were communicated to providers and implemented at follow-up. Data were analyzed using descriptive statistics. PRACTICE INNOVATION: A gap analysis was conducted by including 23 patients seen at the clinic over a 22-month period. The care gaps identified served as the basis for the pilot-program design. EVALUATION: Patients referred to the program were seen over a span of 1 to 2 visits; a total of 19 visits were documented. Pharmacists identified unaddressed issues with mood (68%). Recommendations made to the providers included additional adjuvant therapy (84%), dose adjustment (58%), and laboratory tests (74%). Naloxone was provided (58%), and education on naloxone use was provided at every visit. DISCUSSION: Untreated depression, anxiety, and insomnia were the most common problems identified by pharmacists. Pharmacists implemented and documented risk-reduction strategies and coprescribed naloxone more frequently compared with clinic providers. The program enhanced the pharmacists' ability to make safe and clinically appropriate decisions with regard to filling opioid prescriptions. CONCLUSION: The pilot program identified care gaps and provided an approach for engaging with patients and providers to optimize pain management, implement opioid risk-reduction strategies, and expand naloxone access.

Clinical Pharmacy Services in a Multidisciplinary Specialty Pain Clinic.

PURPOSE: To describe a model of clinical pharmacy services as part of a multidisciplinary specialty pain clinic by discussing (1) the role of a clinical pharmacist in a specialty setting, including clinical interventions implemented, and (2) how integration of a clinical pharmacist may translate into an improved patient care model for the management of chronic pain. METHODS: A retrospective chart review was conducted of pharmacist visits from October 1, 2013, to September 30, 2015, in a specialty pain clinic at an academic medical center in Los Angeles, California. Data were collected regarding medication-related problems (MRPs) identified by the pharmacist, interventions implemented to resolve the MRPs, and types of medication care coordination activities (MCCAs) performed by the pharmacist, such as responding to medication refill requests and insurance issues. Descriptive statistics were used. Institutional review board approval was obtained prior to initiating the study. RESULTS: At least 1 MRP was identified in 98.7% of the 380 visits. Problems identified by the clinical pharmacist were divided into 5 categories: medication refills needed (43%), medication appropriateness/effectiveness (18%), miscellaneous (17%), safety (16%), and nonadherence/patient variables (6%). Interventions focused on referral to appropriate providers, medication counseling, medication initiation, dose adjustment, and medication discontinuation. The most common MCCA was responding to refill requests. CONCLUSION: A clinical pharmacist can identify many MRPs and implement interventions in chronic pain management. Integration of clinical pharmacy services may improve practice management by facilitating the completion of MCCAs and increase access to patients' needs outside the clinic.

Current interventions to promote safe and appropriate pain management.

PURPOSE: Describe patient-, clinician-, system-, and community-level interventions for pain management developed and employed by 9 healthcare systems across the United States and report on lessons learned from the implementation of these interventions. SUMMARY: The high cost associated with pain coupled with the frequent use of opioid analgesics as primary treatment options has made novel pain management strategies a necessity. Interventions that target multiple levels within healthcare are needed to help combat the opioid epidemic and improve strategies to manage chronic pain. Patient-level interventions implemented ranged from traditional paper-based educational tools to videos, digital applications, and peer networks. Clinician-level interventions focused on providing education, ensuring proper follow-up care, and establishing multidisciplinary teams that included prescribers, pharmacists, nurses, and other healthcare professionals. System- and community-level interventions included metric tracking and analytics, electronic health record tools, lockbox distribution for safe storage, medication return bins for removal of opioids, risk assessment tool utilization, and improved access to reversal agents. CONCLUSION: Strategies to better manage pain can be implemented within health systems at multiple levels and on many fronts; however, these changes are most effective when accepted and widely used by the population for which they are targeted.

Long-term Outcomes of the ATHENA (Athletes Targeting Healthy Exercise & Nutrition Alternatives) Program for Female High School Athletes.

Adolescence and emerging adulthood are critical windows for establishing life-long behaviors. We assessed long-term outcomes of a prospective randomized harm reduction/health promotion program for female high school athletes. The intervention's immediate beneficial effects on diet pill use and unhealthy eating behaviors have been reported; however, tobacco, alcohol and marijuana use were not immediately altered (Elliot et al, 2004). One to three years following graduation, positive benefits in those domains became evident, and intervention students reported significantly less lifetime use of cigarettes, marijuana, and alcohol. Sport teams may be effective vehicles for gender-specific interventions to promote competency skills and deter harmful actions, and those benefits may manifest when acquired abilities are applied in new environments following high school graduation.

Topical Ketamine in the Treatment of Complex Regional Pain Syndrome.

The purpose of this study was to evaluate the effectiveness and adverse effects of topical ketamine in the treatment of complex regional pain syndrome. Retrospective charts were reviewed of patients 18 years or older diagnosed with complex regional pain syndrome and treated with topical ketamine during the study period of May 2006 to April 2013 in an academic medical center specialty pain clinic. Exclusion criteria consisted of subjects who 1) were treated with topical ketamine for pain syndromes other than complex regional pain syndrome, 2) initiated other pain therapies concurrently with topical ketamine, 3) had less than two documented visits, 4) began use of topical ketamine prior to the start of the study period, 5) were under 18 years of age. Subjects with ICD-9 diagnoses codes complex regional pain syndrome-1 or complex regional pain syndrome-2 were identified from encounter-based data and billing records. Data collected for each subject included demographics, description of complex regional pain syndrome, concurrent medications and medical conditions, type of ketamine compound prescribed, duration of therapy, side effects, reasons for discontinuation (if any), and pain scores (numerical pain rating scale; 0 to 10). Data were analyzed using descriptive statistics. Institutional Review Board approval was obtained prior to initiating the study. Sixteen subjects met the inclusion/exclusion criteria for the study, 69% of which were female with an average age of 46 years (range: 24 to 60). Subjects took an average of 3.7 other pain medications (range: 2 to 8), had an average of 2.7 other co-morbid pain conditions (range: 1 to 5), and 1.6 other co-morbid non-pain conditions (range: 0 to 4). Eight (50%) reported that their pain had improved, while 7 (44%) reported a worsening of pain. One reported no change in pain score. No subjects reported adverse effects. Based on the findings in this study, the use of topical ketamine in the treatment of complex regional pain syndrome shows promise due to the overall limited options available to treat this condition, as well as the favorable safety profile of topical agents. Future prospective controlled studies are needed to demonstrate a clear benefit.

Definition and outcome of a curriculum to prevent disordered eating and body-shaping drug use.

Almost one half of male and female students participate in high school-sponsored athletics, and high school also is a time when classroom health promotion curricula are less effective. The Athletes Training and Learning to Avoid Steroids is a sport team-centered drug-use prevention program for male high school athletes, which has been shown to reduce alcohol and illicit drug use. Just as anabolic steroid use is associated with male athletes, female sport participants may be at a greater risk for disordered eating and body-shaping drug use. Extending sport team-centered programs to young women athletes required defining and ranking factors related to developing those harmful behaviors. Survey results from a cross-sectional cohort of female middle and high school student athletes were used to identify and prioritize potential curriculum components, including mood and self-esteem, norms of behavior, perceptions of healthy body weight, effects of media depictions of women, and societal pressures to be thin. The derived sport team-centered program was prospectively assessed among a second group of female student athletes from 18 high schools, randomized to receive the intervention or the usual care control condition. The Athletes Targeting Healthy Exercise and Nutrition Alternatives (ATHENA) intervention is a scripted, coach-facilitated, peer-led 8-session program, which was incorporated into a team's usual training activities. The ATHENA program significantly altered the targeted risk factors and reduced ongoing and new use of diet pills and body-shaping substances (amphetamines, anabolic steroids, and sport supplements). These findings illustrate the utility of a structured process to define curriculum content, and the program's positive results also confirm the sport team's potential as a vehicle to effectively deter health-harming behaviors.

Preventing substance use and disordered eating: initial outcomes of the ATHENA (athletes targeting healthy exercise and nutrition alternatives) program.

OBJECTIVES: To implement and to assess the efficacy of a school-based, sport team-centered program to prevent young female high school athletes' disordered eating and body-shaping drug use. DESIGN AND SETTING: Prospective controlled trial in 18 high schools, with balanced random assignment by school to the intervention and usual-care control conditions. PARTICIPANTS: We enrolled 928 students from 40 participating sport teams. Mean age was 15.4 years, 92.2% were white, and follow-up retention was 72%. INTERVENTION: The ATHENA (Athletes Targeting Healthy Exercise and Nutrition Alternative) curriculum's 8 weekly 45-minute sessions were incorporated into a team's usual practice activities. Content was gender-specific, peer-led, and explicitly scripted. Topics included healthy sport nutrition, effective exercise training, drug use and other unhealthy behaviors' effects on sport performance, media images of females, and depression prevention. MAIN OUTCOME MEASURES: We assessed participants by confidential questionnaire prior to and following their sport season. We determined program effects using an analysis of covariance-based approach within the Generalized Estimating Equation framework. RESULTS: Experimental athletes reported significantly less ongoing and new use of diet pills and less new use of athletic-enhancing substances (amphetamines, anabolic steroids, and sport supplements) (P<.05 for each). Other health-harming actions also were reduced (less riding with an alcohol-consuming driver [P = .05], more seat belt use [P<.05], and less new sexual activity [P<.05]). The ATHENA athletes had coincident positive changes in strength-training self-efficacy (P<.005) and healthy eating behaviors (P<.001). Reductions occurred in intentions toward future use of diet pills (P<.05), vomiting to lose weight (P<.05), and use of tobacco (P<.05) and muscle-building supplements (P<.005). The program's curriculum components were altered appropriately (controlling mood [P<.005], refusal skills [P = .05], belief in the media [P<.005], and perceptions of closest friends' body-shaping drug use [P<.001]). CONCLUSIONS: Sport teams are effective natural vehicles for gender-specific, peer-led curricula to promote healthy lifestyles and to deter disordered eating, athletic-enhancing substance use, and other health-harming behaviors.

A comparison of pharmacist travel-health specialists' versus primary care providers' recommendations for travel-related medications, vaccinations, and patient compliance in a college health setting.

BACKGROUND: Pretravel medication and vaccination recommendations and receipt were compared between primary care providers (PCPs) without special training and clinical pharmacists specializing in pretravel health. METHODS: A retrospective chart review of patients seen for pretravel health services in a pharmacist-run travel clinic (PTC) compared to PCPs at a University Student Health Center. Vaccine/medication recommendations were assessed for consistency with national/international guidelines. Medical/pharmacy records were queried to determine the receipt of medications/vaccinations. RESULTS: The PTC recommended antibiotics for travelers' diarrhea were given more often when indicated (96% vs 50%, p < 0.0001), and patients seen in the PTC received their medications more often (75% vs 63%, p = 0.04). PCPs prescribed more antibiotics for travelers' diarrhea that were inconsistent with guidelines (not ordered when indicated 49% vs 6%, p < 0.0001 and ordered when not indicated 21% vs 3%, p < 0.0001). The PTC prescribed antimalarials more often when indicated (98% vs 81%, p < 0.0001), while PCPs prescribed more antimalarials that were inconsistent with guidelines (not ordered when indicated 15% vs 1%, p < 0.0001 and ordered when not indicated 19% vs 2%, p < 0.0001). The PTC ordered more vaccines per patient when indicated (mean = 2.77 vs 2.31, p = 0.0012). PTC patients were more likely to receive vaccines when ordered (mean = 2.38 vs 1.95, p = 0.0039). PCPs recommended more vaccines per patient that were inconsistent with guidelines (not ordered when indicated: mean = 0.78 vs 0.12, p < 0.0001, ordered when not indicated: mean 0.18 vs 0.025, p < 0.0001). CONCLUSIONS: A pharmacist-run pretravel health clinic can provide consistent evidence-based care and improve patient compliance compared to PCPs without special training. Pretravel health is a dynamic and specialized field that requires adequate time, resources, and expertise to deliver the best possible care.

Mosquito-borne illnesses in travelers: a review of risk and prevention.

In 2008, residents of the United States made 12 million visits to developing countries in Asia, South America, Central America, Oceania, the Middle East, and Africa. Due to the presence of Anopheles, Aedes, and Culex mosquitoes, travel to these destinations poses a risk for diseases such as malaria, yellow fever, and Japanese encephalitis that cause significant morbidity and mortality. To gain a better understanding of the major emerging and established travel-related infectious diseases transmitted principally by mosquitoes and the measures for their prevention in U.S. residents who travel to these developing countries, we performed a literature search of the PubMed and MEDLINE databases (January 1950-February 2010). Information from the Centers for Disease Control and Prevention and the World Health Organization and relevant references from the publications identified were also reviewed. Vaccines for the prevention of Japanese encephalitis and yellow fever are commercially available to U.S. travelers and should be administered when indicated. However, the prevention of malaria, dengue fever, chikungunya, and West Nile virus relies on personal insect protection measures and chemoprophylaxis for malaria. As the rate of international travel continues to rise, individuals traveling overseas should be made aware of the risk of various infectious diseases and the importance of prevention. Physicians, pharmacists, nurses, and other practitioners can play a vital role in disease education and prevention, including the administration of vaccines and provision of chemoprophylactic drugs.