Middle aged, fragile and small female, presents to our out-patient pharmacy, dressed in a thick sweater and furry hat, even though the ambient temperature is in the low 70’s. The furry hat appears to not only be keeping her warm, but also covering her bald head. She has appeared at our pharmacy because she stated she was treated like a drug addict at the big box pharmacy she had been using and never wants to go back there. She lifts off her hat as if to prove her statement that she is undergoing chemo therapy and show us that all of her hair has fallen out.
Patient presents with a prescription for Morphine 20mg/ml, 120ml, sig: 0.5-1ml (10-20mg) po q4-6h prn pain. Patient is new to us so we gather demographic information. Review of our states Prescription Drug Monitoring Program shows previous prescriptions on a monthly basis for last two months along with alprazolam 0.5mg. Prescribing physician is the same on both PDMP prescriptions as is on the current prescription in front of me and the physician practices within one mile of pharmacy. Prescription appears legal, timely, and appropriate for physician and diagnosis.
Upon review of the PDMP I realize that the patient has not been taking a long acting narcotic for her cancer pain, only the short acting morphine. Patients with extended pain control needs will often be prescribed a long acting medication taken once or twice daily or a patch that is placed every two or three days. The patient will then use the short acting medication for the in between or breakthrough pain.
If you draw a graph of time (x-axis) versus level of pain control (y-axis) it is easy to see that in this situation, a short acting medication will have multiple spikes over 24 hour, quickly breaking through the pain threshold to a high level, only to fall again within a couple hours down below the pain threshold. These spikes are associated with side effects. In this scenario, a patient needs to plan their day around making sure they always have pain medication with them. They may find that they are limited in their activities and outings due to inadequate pain control and may realize they are constantly looking at the clock to see if it is time for their next dose.
Next, draw what a long acting pain medication may look like on the graph. We have a long sloping curve that, over the course of 1-2 hours reaches the pain threshold and continues slightly above the threshold for 8 hours, then falls back below. On the graph it is easy to see that taking the short acting, breakthrough pain medication at strategic times along with a long acting medication may allow for an extended period of comfort with fewer medication related side effects. This process also allows for an increased quality of daily activity time.
Plan: (What are the important counseling items to address?)
First, I want to address the comment that she made when she came in about being treated like a drug addict at the big box pharmacy she had been to. I will explain to that we treat pain as any other disease, just as we treat cholesterol, diabetes and high blood pressure. Of course, we perform due diligence, as stated above, and we do not hesitate to call a physician to discuss the appropriateness of therapy when warranted. Calling patients treated for pain drug addicts is as inappropriate as calling diabetic patients sugar addicts.
We will then have a discussion about her morphine, with her teaching back to me how she uses it, how well it works for her pain control, what side effects she looks out for and has experienced, how she stores it and any other information she may have about the medication. I will fill in the gaps and answer questions as we go along. Even though this is a refill prescription, it is new to our pharmacy. It is important that the dispensing pharmacist take the time to assess how the patient has been using this medication over the past 2-3 months.
Lastly, we will discuss the theory of a long acting narcotic vs a short acting narcotic, with the understanding that by adding a long acting medication she may be gaining a level of pain control, increased quality of life, and a decreased level of “spike” side effects. Before the counseling session is complete, I will offer to call her physician to discuss her pain control regimen with her physician.
Steve Leuck, Pharm.D.
I’m think your case is very interesting, checking the appropriateness and validity of the morphine prescription is a must. Adding in a long acting opiate analgesic would be entirely appropriate in this patient, lessening frequency of side effects and giving more adequate pain control. Using the morphine only for breakthrough pain. A good case to learn from thanks for the post.
Ajay: Thanks for your thoughtful reply. I know when it gets uber busy in the pharmacy it is sometimes tempting to overlook situations that may benefit from a little one on one counseling. This was definitely one of those situations and a little bit of patient education went along way!
Out of personal curiosity, why was the concentrated morphine solution being used? If there was chemo-induced dry mouth or difficulty swallowing, I’d think lorazepam solution would have also been used instead of alprazolam tablets.
Jeff, thanks for your reply and excellent questions. Re: the morphine solution, I had the same question. When I asked the patient what she had tried already she stated she had been on a hydrocodone/apap combination and it wasn’t helping the pain. She explained this to her oncologist who then chose to prescribe the morphine solution combination. She stated that her physician felt the morphine would provide better pain control and she was almost apologetic that her oncologist had not explained to her his theory on pain control.
This brings up a concern that we all need to be aware of in the outpatient pharmacy world. Medical oncologists, along with understanding chemotherapy, need to also be pain specialists. As stated in the Journal of Clinical Oncology2011 (JCO Dec 20, 2011:4769-4775; DOI:10.1200/JCO.2011.35.0561.) “Limitations in oncologists’ knowledge and practices relating to pain management may be contributing to a substantial unmet need in populations with cancer.” The majority of oncologists acknowledge that the quality of the pain management training they received to be only fair. I am certain that if a patient was being treated by a pain specialist and developed cancer that the pain specialist would refer the patient to an oncologist. This is not the case with oncologists. By default, oncologists must also understand pain management.
Regarding the aplprazolam vs lorazepam; patient did not present with chemo induce dry mouth so liquid lorazepam would not have been necessary. In the out-patient setting we need to be diligent with our time in order to strengthen our ability to discern which issues need immediate attention vs. which situations may be taken care of at another visit. In this situation, the patient was already stabilized on the liquid morphine solution and had already been to another pharmacy. It would have been unreasonable to call the physician, interrupt his daily practice to have him re-evaluate this patients pain regimen, and then send her back to the doctor for another schedule II prescription. Spending a few moments helping the patient understand the theory of long acting vs. short acting pain control she is now in a position to take her educated questions back to her own physician.
MDs can now e-prescribe opioids so that might help make pain management more efficient for chronic pain patients like this one.