CEimpact Podcast

Pain Management Tips and Updates for Pharmacists

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Pharmacists are key partners in helping patients navigate the challenges of managing pain safely and effectively. This episode covers practical strategies for counseling, identifying potential concerns in therapy, and supporting appropriate treatment, plus a quick review of the newly approved non-opioid option. Tune in to strengthen your clinical confidence and improve outcomes in pain care. 

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Lorin Fisher PharmD, BCACP
Residency Program Director
University of Iowa

Joshua Davis Kinsey and Lorin Fisher have no relevant financial relationships to disclose.

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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Recognize essential counseling points and patterns in medication use that pharmacists should address when managing patients with pain.
2. Describe the role of pharmacists in supporting safe and effective pain management, including awareness of newly approved medications.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-258-H08-P
Initial release date: 7/28/2025
Expiration date: 7/28/2026
Additional CPE details can be found here.

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Speaker 1:

Hey, ce Impact subscribers, Welcome to the Game Changers Clinical Conversations podcast. I'm your host, josh Kinsey, and, as always, I'm excited about our conversation today. Pain is one of the most common reasons patients seek care and one of the most challenging to manage safely and effectively. In this episode, we'll explore how pharmacists can play a pivotal role in guiding therapy, supporting patients and staying current on the latest tools and treatments. Lauren, it's so great to have you today. We have Lauren Fisher with us today as our guest expert. Thanks for joining us.

Speaker 2:

Thanks so much for having me, josh, I appreciate it.

Speaker 1:

Yeah. So for those listeners out there who haven't had the pleasure of meeting you yet or you've done other work for CE Impact at different events and sessions, but for those that haven't met you yet, if you'll take just a couple minutes, lauren, to kind of introduce yourself and tell us about your practice side and your passions in pharmacy, sure.

Speaker 2:

So I'm Lauren Fisher. I am a clinical assistant professor at the University of Iowa College of Pharmacy in Iowa City, iowa. In my clinical practice role I am a clinical pharmacy specialist at UI Healthcare in the supportive and palliative care clinic and, of course, related to my role in academia, I do research as it relates to palliative care and pain management, as well as teach those topics in our PharmD curriculum and I take APPE and IPPE students on rotation as well. I also have a faculty appointment with our Hospice and Palliative Medicine Fellowship over at UI Healthcare, so I'm involved in the training of those postgraduate medical trainees as well.

Speaker 1:

Great, you don't sound like you have anything to do, lauren, so let me see if I can find you some other tasks.

Speaker 2:

I'm sure you can come up with something.

Speaker 1:

You sound very busy, so that just further proves my thanking you for taking out of your busy schedule for joining us today. So I really appreciate it. All right. So, as I mentioned earlier, our topic for the day is pain management. I always like to set the foundation for our listeners, just to make sure that everybody's remembering things that they learned in pharmacy school. It might be fresh on some people's mind, it might be, like me, where it's 20 years old. So just kind of resetting the foundation, so just kind of remind us the different types of pain that we may encounter with our patients and just kind of overview of pain management in general for just a few minutes with our patients and just kind of overview of pain management in general, for just a few minutes, sure.

Speaker 2:

So I think, first thinking about different types of pain in terms of chronicity, so that breaking it down into acute pain versus chronic pain. So acute pain typically occurs up to one month following the time of tissue injury or an inciting incident, so the development of a tumor that you know is having a significant impact on, you know, a given part in the body, whereas chronic pain is pain that extends three months beyond the time of what we'd expect to be normal tissue healing. And then there's this like subacute pain that, like the CDC defines as that one to three month period. So that's in terms of chronicity. Then I like to think about different types of pain in terms of the character or what it may feel like to the patient.

Speaker 2:

So nociceptive pain, and that is really like what we typically think of as acute type pain. So that's like the sharp poking type, sensation type pain. So that's like the sharp poking type sensation and really that can be due to inflammatory type conditions. So either osteorheumatoid arthritis, it can be due to something like a sunburn, it can be due to like a cut and that propagates very fast pain signals to the brain, and that's why you feel like the sharp poking type sensations. Neuropathic pain, on the other hand, usually has more of a slower conduction, and it typically occurs when there is damage to the nociceptive pain pathway, and so the typical types of sensations are that or more like dull, burning, pins and needles type sensation. And then there's this thought of something called nociceptic pain, which is essentially the transition of more of like acute nociceptive pain into more of like a chronic neuropathic pain. That's related to some types of topics, like related to hyperalgesia and allodynia, which maybe we can get into a little bit more later.

Speaker 1:

Okay, interesting. That's definitely a term I have not heard before. What was it again? Nausea, plastic Nausea plastic pain. Nausea plastic. Okay, very interesting. Yeah, that's a great overview. So thank you for laying that foundation again and just reminding us of the different types, and I think it's interesting. I guess my question is, like patients who have diabetic neuropathy, like where, where does that pain fit in? Like when you mentioned the different types, where would you put that pain that's in more of the chronic right? I would assume. Yeah, okay, okay.

Speaker 2:

And and definitely along obviously, neuropathic sensations just based on how patients typically present with their with their symptoms, right.

Speaker 1:

Okay, okay, I just know that. That you know, obviously, diabetic patients are a large chunk of the people that we take care of as pharmacists, so that's something to just make sure that that pain falls in these categories that you were talking about.

Speaker 2:

So, yeah, and I think the other piece I'll just add real quick is that with Nazi plastic pain, excuse me, nazi septic pain. Rather it is really more in like a specific pinpoint location, the toes and then spread up the leg. That's something I also commonly see in my clinical practice related to chemotherapy-induced neuropathy as well. So if you're seeing more of a radiation of the pain picture, it's usually more of a chronic neuropathic picture.

Speaker 1:

Got it. Yeah, that makes sense. Okay, so it's a burden, right Like pain is a burden. It's a burden to the patient. It's a burden to the health system. It's a burden, right Like pain is a burden. It's a burden to the patient. It's a burden to the health system. It's a burden to the community. So let's talk about that just a little bit, that the impact, the public health impact that pain has and the prevalence of pain. I don't know if you have any sort of stats to share about how many people present with pain or different types.

Speaker 2:

Yeah, I was actually glancing at those before we started.

Speaker 2:

It's estimated that about 50 million Americans experience chronic pain. So, like you said, this is a significant impact and it is really something that we, as pharmacists, can play a significant role in addressing. No matter your practice setting whether you're an ambulatory care practice, like myself, whether you're on more of an acute side and working in a hospital setting, or if you're in a community practice setting More often than not you're probably going to have a patient that experiences some type of painful condition. In terms of like, the impact on like, function and quality of life, there can be significant impacts, so, obviously, reduced physical functioning, like reduced mobility, fatigue. Pain can also lead to reductions in social functioning, so decrease doing recreational activities, social activities that maybe they were able to do prior to the development of the painful condition, and it can have an impact on our mental health as well, developing things like depression, anxiety and also suicidality. A study that I looked at showed that about 9% of individuals that committed suicide did have an underlying chronic pain condition, and I think that's probably somewhat of an underestimation.

Speaker 2:

So it is a real concern that we should be taking about, because pain has such a strong emotional component.

Speaker 2:

So, while pain goes through its neurotransmission and you feel this is pain, it has to pass through the limbic system, and the limbic system is where we develop. Our emotional responses to so many other stressors that we have in life can really be impacted when we have a painful diagnosis on top of that. So it is really important to view pain in a multifaceted way and appreciate the strong emotional component with it. Getting to the financials that maybe you asked about, the estimated national cost for chronic pain is $635 billion per year. Billion with a B, that's crazy. And so what goes into that calculation? Obviously, individual costs to patients, lost productivity at work and then direct health care costs as well productivity at work and then direct healthcare costs as well.

Speaker 2:

Over the last decade or more, there's been so much in the news and at the height of our minds as pharmacists, related to opioid epidemic and opioid-related deaths. I looked at the most recent statistics for that and it actually shows, between 2023 and 2024, that overdose-related deaths secondary to opioids has gone down about 34%, which is absolutely wonderful.

Speaker 1:

That's amazing.

Speaker 2:

Yeah, going from about 83,000 deaths in 2023 to about 55,000 deaths in 2024.

Speaker 1:

Wow. So, Still a long way to go, but still a long ways to go right, trending in the right direction.

Speaker 1:

So, right, yeah, yes, and you know. I just would like to reiterate, how you know, pain puts a burden on the patient's quality of life in more ways than just you know. I feel pain, like you said, it's that whole emotional component, because if you're not able to go to work, or if you're not able to go have dinner with your friends, or if you're not able to exercise, it can have that emotional stress and it can, like you said, build up with depression or anxiety and eventually lead to suicidal ideations as well. So, yeah, it's definitely something to understand.

Speaker 1:

One thing else I wanted to point out and maybe talk about a little bit is patients have different perceptions of pain as well. Right, like you know that there's the whole. I don't I think it has fallen out of favor with the pain scale, but, but you know, you think about that where someone may be experiencing the same type of pain, two people and one's going to feel it a lot more than the other and it's going to be debilitating more for one than the other. Perhaps, you know, is there anything like to add to that? I mean, from your perspective of how perception of pain.

Speaker 2:

Yeah, so really the numeric rating scale. So like that, zero to 10 pain scale it is so subjective and really pain in general is extremely subjective due to the strong emotional component and the underlying pathophysiology that could be going on. One thing that I didn't mention earlier, when I was talking about acute versus chronic pain, is that acute pain is natural and, if anything, it's somewhat healthy. It's our body's homeostasis to respond to a painful stimulus.

Speaker 2:

Chronic pain is not. That is a maladaptive state. So I think that is important to think about. But really, those numeric pain ratings, I don't really take a lot of stock in those. When a patient comes to me in clinic and we're following up on a analgesic change that we made in the last month. For me what's most important is having an understanding of what their functional capacity is. So it is helpful at baseline to know what is your pain preventing you from doing, and so I utilize a mnemonic, just kind of alphabetically PQRSTU, and that U component is how is your pain affecting you? And that's something that any pharmacist can ask about.

Speaker 2:

Some of the other things in that assessment is P stands for precipitators or palliators. What makes pain better, what makes it worse? P, Q quality so what does your pain feel like to you? R region radiation we kind of talked about that a little bit already. Right, Severity could be like that zero to 10, where are you at? But sometimes patients really struggle with numbers. So asking about, you know, is this more of an annoyance? Is it an aggravation? Is it preoccupying your mind, Is it excruciating? So maybe just asking that severity question a bit of a different way. Timing is it intermittent, Does it come and go? When did the pain start? And then, ultimately, the impact it has on function.

Speaker 2:

So, that is a good tool that I like to ingrain. In my mind it's been ingrained probably since I was a pharmacy student, because it's so easy to remember but, again, any practice that you're in, I feel like that's a really quick and easy assessment that you can use to ask open-ended questions, Absolutely easy assessment that you can use to ask open-ended questions?

Speaker 1:

Absolutely, and is that something that you developed or you saw developed, or is there like a place that our listeners can go to kind of get that resource and have that?

Speaker 2:

No, so I did not develop that it is just generally speaking, if you look at lots of different paying textbooks, this is something that is just generally recommended for history taking.

Speaker 1:

So yeah, okay, that's great. No, it's good. I just know that a lot of times our listeners are not to where they can write something down, so I want to be sure they can find that again. So that's great, great stuff. And I love how you talked about changing up the numeric scale into more of like, is it debilitating, is it excruciating? Is it just annoyance? Is it aggravation? You know, like, because sometimes people the words resonate more with them than like. I know I struggle if I've ever had been in the hospital with surgery or whatever.

Speaker 1:

Yeah, it's like I don't know what is. What is seven mean Like right, exactly. Is that? Does that mean I'm just like, yeah, it hurts, I noticed it, so it's a seven. Or does that mean, oh, I can't do anything because it's debilitating, so Right?

Speaker 2:

Yeah, and as a clinician, like what do we, what do we do with that number?

Speaker 1:

Like Right so.

Speaker 2:

So then some people may ask then what is a like a clinically significant reduction in pain? Right, so some studies have determined that a three-point reduction on a 0 to 10 scale, so like a 30% reduction, is deemed to be clinically significant. But that kind of standard, so to speak, is not universally applied in all studies analgesic efficacy studies. So I think that is important to kind of keep in mind. But then it's like well, what is a three point reduction really even mean?

Speaker 1:

Yeah, yeah, and, and it, and maybe it makes more sense to to talk about it in a in a sense of a 30% reduction, like, are you now 30% more active with something because your pain is gone, or whatever? So, yeah, very interesting, okay, so we've talked a little bit about, obviously, the pharmacist is well positioned, despite, regardless of their practice, setting their opportunities. So I'd like to dig into some of those opportunities. So we've talked about staying that. There are plenty of tools and resources. You've mentioned some, so staying up to date on those is super important. Is there anything that you can add for the listeners about, like, where to stay up to date on those is super important. Is there anything that you can add for the listeners about, like, where to stay up to date on those, or what are some good tools or resources to kind of access or utilize in this space?

Speaker 2:

Absolutely so. Oftentimes, with analgesics in particular, we're very concerned about drug-drug interactions. So there are a few tools that I like to utilize about drug-drug interactions. So there are a few tools that I like to utilize. So I definitely use like a typical tertiary resource like Micrometics LexiComp to make sure that I'm doing a thorough drug-drug interaction check there. I also utilize a tool from Indiana University known as the Flockhart table. That table what it essentially does is it lists out drugs based on whether or not it is a substrate for a cytochrome P450 or SIP enzyme.

Speaker 2:

And then it lists also what examples of inducers or inhibitors are of that enzyme and so given drugs, and then, to what degree are they inhibiting or inducing? Are they a weak, a moderate or a strong inducer? Or inhibitor so that can be really helpful, especially if I'm dealing with a medication that has difficult pharmacokinetic considerations or pharmacodynamic considerations like methadone, so that is a really good source I like to use.

Speaker 1:

Or if you're dealing with a patient that has a lot of comorbidities and they're on a lot of medications and yeah, yeah exactly.

Speaker 2:

There's also a tool that I like to use called the Credible Meds, and I'm sure others maybe have talked about it on this podcast, but it essentially is a free resource that you can you sign up for an account and you can determine the relative risk of QTC prolongation with various medications Again, different types of analgesics I'll call out methadone again but also things like SNRIs, tricyclic antidepressants.

Speaker 2:

We do have to worry about the cumulative risk for QTC prolongation, especially, like what you said earlier, when we think about patients that may have a comorbid cardiac condition. So that can be a really great resource as well. What I like about it in particular is that it pulls the specific studies that cite the relative risks. So credible meds is a really good one. And then also I think about, like, what the anticholinergic burden is of given medications and while the tertiary resources like Lexicomp and Micromedex may calculate that, it may not be to the level of appreciation that I'm hoping to get, to kind of think about what impact could this have on the patient. So the ACB calculator, or their anticholinergic burden calculator, is another really great tool I like to use.

Speaker 1:

That's a new one for me. I haven't heard of it. Yeah it is.

Speaker 2:

It is really great. It kind of similar to, like the tertiary references you can just type in various medications and it can tell you the degree of high versus moderate, versus low anticholinergic burden. So I kind of have a theme of thinking about, like what is the cumulative risk of given medications for an individual's patient's condition and as well as what other conditions they may have and what other medications they may be?

Speaker 1:

taking. Yeah, no, that's great. All great helpful information and tools and resources. Medications they may be taking yeah, no, that's great. All great helpful information and tools and resources. So, yeah, sharing those. So now I want to kind of move into talking about specific treatment, like specific options that are out there. I think you know talking about OTC versus prescription. We'd be remiss if we didn't talk a little bit about the newest medication on the market. That's the first non-opioid in a long time.

Speaker 1:

Yeah. So yeah, if we can kind of go down the path of talking just a little bit about reminding us what treatment options are out there OTC prescription, some of the newer stuff and just kind of going into that space for a little bit, Sure.

Speaker 2:

So I mean I'll kind of set the stage a little bit of talking about the WHO or World Health Organization analgesic ladder, which I'm sure a lot of us are familiar from our time in pharmacy school or just using it in practice. So the first rung, or the lowest level for mild pain, we really should be thinking about non-opioid therapies. So this can include things like acetaminophen or NSAIDs, but it may also include adjuvants as well, and when I say adjuvants I'm typically thinking about medications that were not initially FDA approved for pain management but, there's evidence to show that they have analgesic benefits.

Speaker 2:

So that would be things like anticonvulsants ranging from gabapentinoids to sodium channel blockers and SNRIs as well. Then the next rung is that moderate pain, which the WHO defines as considering using weak opioids, as well as non-opioids and adjuvant analgesics. Now, what they call weak opioids are tramadol, hydrocodone, acetaminophen. Opioids are tramadol, hydrocodone, acetaminophen and codeine-containing products. Personally, I have some concerns with that term weak opioids, because tramadol and codeine in particular have significant pharmacogenetic variability because of their involvement with the CYP2D6 enzyme, so that can ultimately have an impact on the efficacy or the non-efficacy of those. So also, there's really been no head-to-head studies to show what opioid may be better than another one. So I think the term weak is something that you know may lead to a false sense of safety.

Speaker 1:

I was gonna say it seems a little misleading if-.

Speaker 2:

Exactly, yeah, yeah. And then the top rung of the analgesic ladder is for more persistent and severe pain.

Speaker 2:

So that would be where we would think of the traditional mu opioid receptor agonist. So, like your oxycodone, your morphine, your hydromorphone, as well as using in combination with non-opioid analgesics and adjuvants, and because all of those analgesics have different mechanisms of action along the pain signaling pathway, it really is important to use a multimodal regimen, so medications with multiple mechanisms of action right To get the most bang for your buck. So I'll circle back to the question that you had about the new medication that was FDA approved at the end of January, called Zetrogene.

Speaker 2:

It became like available, probably for people in practice to use, around March. I will give a full disclaimer I've not yet used it in my practice but I've significantly investigated it because I think that there could be great possibility for future use in chronic pain, which is the area that is most relevant to my clinical practice. The area that is most relevant to my clinical practice, as sugetrogene right now only has an FDA indication for acute pain management.

Speaker 1:

Okay.

Speaker 2:

So it is a voltage-gated sodium channel 1.8 inhibitor. So that particular type of sodium channel is only present in the peripheral nervous system. There's nine different types of sodium channels and they're located within the heart, within the central nervous system, within the peripheral nervous system. But 1.7, 1.8 and 1.9, those three types of sodium channels are just in the periphery. There's currently some investigative work looking at analgesics specific to 1.7 and 1.9 right now, but there's nothing that's FDA approved for those at this time.

Speaker 2:

So there are other sodium channel blockers that y'all may be familiar with. So that can be something like lidocaine, myxillatine, oxcarbazepine, carbamazepine, lacosamide, but those are non-specific sodium channel blockers. So there is a possibility of having neurologic and or cardiovascular adverse effects. But what's great with sujetrogene is that it does not have it's really not been shown to have any of those off-site adverse effects. What the two randomized double-blind placebo-controlled studies have shown is that there is a less than 5% incidence of adverse effects with suzetrogene, and the most common being things like itching, muscle spasms and elevated creatine kinase, which at this point it doesn't seem like that is clinically significant. That elevation, again, since it has the FDA indication for acute pain only it really has not been studied for longer than a 14-day duration, and so that is something to take into consideration.

Speaker 2:

There's currently phase two studies that are going on right now with sugetrogene for the management of lumbosacral radiculopathy, so that's basically low back pain radiating down to the legs, and then also for painful diabetic neuropathy as well. So we have some preliminary results from the lumbosacral radiculopathy study. There was a high placebo effect in that study and I feel like that's just a trouble with doing pain research in general because there can be really high placebo effects. But they are doing a subgroup analysis and furthering that study to see if they can not see as much of a pronounced placebo effect.

Speaker 1:

Okay, interesting. Yeah, wow, that's a great overview of that drug and again, it's kind of. I think its promise is big and I'm hopeful that it will continue with the studies and be able to be indicated for additional use and be effective at that. It's also interesting to note that it's not going to have some of those negative cardio side effects and everything like the others that you mentioned in that class, so that's good. Or in a similar class. Okay, well, that's very helpful. I was transported for a few seconds when you were describing it with the voltage thing. I thought we were talking about something totally different. That's a normal term that we hear talking about medications.

Speaker 2:

Yeah, I mean there's so much related to electrical action, potentials of how our get transmitted. So in the peripheral nervous system there's so much opening of those sodium channels, and so that can be a really great target for inhibiting further propagation of those signals.

Speaker 1:

It's just fascinating how you know research found that pathway and determine how to kind of work with it. So yeah, yeah great, it's really great. I'm at a loss for words. It just sounds, it's so I don't know. It just is so high tech and we've come so far with drug research and development, so it's great. One of the things I wanted to talk about, too is another opportunity for pharmacists is to really, you know, we always talk about lifestyle modifications when we're talking about other comorbid disease states, you states like diet and exercise and things like that, and those things are also super important and helpful for our patients that are undergoing pain management as well. So if you can speak just a little bit about the importance of activity and sleep and some of those as kind of add-on therapies to the typical treatment for patients, yeah, definitely Kind of to get to sleep right away.

Speaker 2:

If we have a patient that's struggling with sleep, that can really have an impact on the healing process. However, if pain is interfering with sleep, sometimes we may have to think about optimizing or intensifying our analgesic regimen to allow the patient to have adequate sleep. Now we want it to be good REM sleep, not like an induced sleep state due to adverse effects of medication. So that's something to think about. Is you know, do we need to optimize an analgesic regimen to allow for adequate sleep? Exercise can be really important in enhancing pain, especially for conditions like fibromyalgia and chronic low back pain as well, being careful to be mindful of utilizing like non-weight-bearing exercise routines. So water aerobics can be a really great tool.

Speaker 2:

In my clinical practice. We definitely have functional limitations for patients living with serious illnesses like cancer. So kind of trying to set those like functional goals or like what are they hoping that they can do? And so coming up with a plan of like maybe you know, going out for a walk a couple of times a week, getting to go back to church if they've not been there in so long, and like how can they have people in their life help them achieve their functional goals. So I think that is also really important to think about, as it relates to expectation setting and kind of coming back to like, functionally, what do you want to be able to do?

Speaker 2:

And is that realistic in the context of your disease? And your current state of pain management.

Speaker 1:

Yep, and you segued perfectly into my next point, which I wanted to get into some of those barriers and challenges that we face with these patients, and one of those is managing the patient expectations, and so you spoke to that very well just recently about how we need to make sure that we're asking about their function, you know, and determining. Did we improve that with their drug regimen or the plan that we had put into place? So, anything else to talk about on how to better manage patients' expectations around pain relief.

Speaker 2:

I think it's important to be consistent in asking about expectations, especially even like when we're leading up to something that could have a significant impact on pain, like a major surgery. So collaborating with a surgeon potentially to say you know what is a realistic expectation for you know X months out following the surgery of what the patient's pain may be.

Speaker 2:

Talking to rehabilitation colleagues like physical therapists about, you know what is realistic as it relates to functional goals. So, as a pharmacist, we can definitely forge those relationships, and that's just really something I want everyone, regardless of your clinical practice, to think about is how can you engage with interprofessional colleagues to enhance pain management?

Speaker 1:

Yeah, I always love opportunities to collaborate, so thank you for bringing that up. One thing I'd like to address to a challenge is the fear of opioids. You know, with you mentioned earlier in the last decade or so, really come into light with the opioid epidemic and you know, I think there's a lot of and rightfully so a lot of negativity around it and a lot of misconceptions as well and fears. So how is that some? How do you approach that in a patient when you see that they are fearful of going on it and they really need it, or they're fearful of you know how long am I going to be on it, or whatever? What's some of those conversations look like?

Speaker 2:

whatever. What's some of those conversations look like? Yeah, I'll talk about fear in the context of the patient first, but I think the opioid epidemic has really sparked fear, not just with patients but with the entire medical community.

Speaker 1:

Oh, for sure. Yeah, even with providers.

Speaker 2:

Right, there's been a significant reduction of opioid prescribing over the opioid epidemic, which is good, where some of those opioids may be not the most appropriate thing to be prescribed.

Speaker 2:

But what about the patients who may need them, that are living with a serious illness and there is a fear from a primary care provider or an oncologist to prescribe opioids and then that leads to undue suffering because of that fear. So I think that that is something real and I think also it's something that we as pharmacists should be like checking as well. As I see a prescription for a large quantity of opioids, Like do I know what the indication is? Is this something that you know would warrant a larger quantity or a particular opioid selection? So I think that that's important, that, as pharmacists, that we make sure that we're up to date on education, not just for you know, thinking about opioid stewardship or pain stewardship, but also for conditions like serious illnesses that may require kind of some of the outliers as it relates to high intensity pain management that may be with opioids.

Speaker 2:

But, to get back to your original question, like for patients, particularly in my area of clinical practice in palliative care, yes, we're prescribing what some people may think of as high-intensity opioids, so like morphine, oxycodone, hydromorphone and extender-release opioids as well like fentanyl and methadone. And when we call out specific opioids or just bring up the word opioids, you're right, it can cause an innate fear and patients that may be living with stage four cancer ask am I going to get addicted to this? So I think it's important that, as pharmacists, we're very familiar with the terms addiction, tolerance and dependence, because those three terms can be confusing. For us they can be confusing, but also for patients as well.

Speaker 2:

For us, they can be confusing, but also for patients as well. So addiction is inappropriate use of any medication opioids in this example and that could lead to possible diversion. So using opioids for things other than pain and trying to acquire them by other inappropriate means. Tolerance is essentially when an individual is on a dose of a medication and after a prolonged period of time, that dose is no longer effective. It's a biological phenomenon. Josh, if you and I were on opioids, if for a period of time, tolerance would happen to us.

Speaker 2:

So that is expected and to be normal, and I tell patients that if that occurs, that's when we think about doing a rotation to a different opioid medicine, or to think about increasing or changing the dose. And then dependence essentially means that if an individual were to rapidly discontinue or just stop taking their opioid medication, they would experience withdrawal effects. Or just stop taking their opioid medication, they would experience withdrawal effects. So withdrawal effects meaning things like diarrhea, worsening pain, nausea, vomiting, chills, tremor, that type of thing, and again, that would be something that you and I would experience as well if we were in that situation. And so I think normalizing especially tolerance and dependence, are things that we would expect to happen under specific scenarios is important for patients to know, and then we also, you know, provide reassurance that they're taking opioids for a legitimate medical purpose.

Speaker 1:

Yeah yeah, I love that explanation that you just gave, like that was so good. The addiction versus tolerance versus dependence I mean that I feel like sometimes they just get thrown into the same category and it's all viewed as negative and it's all viewed as like risk behavior and whatever.

Speaker 1:

So I really appreciate that further explanation on that. That was really helpful. Well, unfortunately we're running out of time. What else, Lauren? Is there anything else in the space that you really wanted to be sure that you shared with our listeners today, before we start wrapping up, Anything else that you want to infer upon?

Speaker 2:

Sure, I mean, I think, just to emphasize the point that I made earlier from the perspective of opioids and just pain in general. It can seem very complicated, very scary, there can be a stigma associated with it, but as pharmacists, we are some of the most accessible healthcare professionals and it's essential that we remain educated in this area and also to approach pain management with a sense of curiosity and concern for the patient, not necessarily as being a gatekeeper, looking for red flags, so to speak, and kind of being on the defensive.

Speaker 2:

It's really important, you know, to connect with your patient, to inquire about how they may be taking their pain medications and how they may be able to help, whether it's connecting with a provider that they may be working with, whether it's giving recommendations about dose adjustments, whether it is talking to providers about side effects we really play a pivotal role.

Speaker 1:

Yeah, absolutely, that's great. You know, I always taught my students when I was in academia we have to be sleuths and I've mentioned that before on the podcast, my favorite team, one of my favorite TV shows of all time is Murder. She Wrote, and I love just how inquisitive she is and how JB Fletcher always asks the questions, and so I used to always tell them you got to be like a JB Fletcher, you have to ask the questions, write down the information, put the pieces of the puzzle together, and I think that is exactly what you're saying with these patients as well. So, rather than initially jumping to conclusions, or oh, it's a, it's an opioid prescription. It's definitely a red flag. What are they diverting it? You know, whatever it's asking the questions trying to understand, you may not realize that they've just went through a cancer diagnosis, you may not realize that they're undergoing some other type of treatment, or, or you know, surgery or something. So, so, yeah, I think it's really important that we're asking the right questions and then making an informed decision as that provider for them.

Speaker 1:

So, yeah, such great stuff, lauren. Thank you so much. This was very, very helpful and just kind of reminding us all about pain management and how it is complex, but yet it's not that complex, it's doable, right Like. It's something that we should all have a hand in and we should all be doing so well. Thanks again. Super appreciate you spending time out of your busy schedule. So thank you.

Speaker 2:

Yes, thank you for having me. I appreciate it.

Speaker 1:

Absolutely. If you're a CE plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at CEimpactcom. And, as always, have a great week and keep learning. I can't wait to dig into another game-changing topic with you all next week.