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.