ASHP Best Practices Award Mortar and Pestle

Award Information

Implementation of a Pharmacist Directed Pain Management Service in the Inpatient Setting

Richard H. Poirier, B.S., Pharm.D., Clint S. Brown, Pharm.D., Yleana T. Garcia, Pharm.D., BCPS, Nicole Y. Gann, Pharm.D., Rheta A. Sandoval, Pharm.D., James R. McNulty, Pharm.D.


Kaweah Delta Healthcare District, Visalia, California

With approximately 100 million adults in the United States affected by chronic pain, it has been estimated that the total financial cost ranges from $560-635 billion. As a result, many agencies have called for improved pain management and patient satisfaction while linking institutional reimbursement to such domains. Over a 6 month period, our executive committee worked with medical and pharmacy staff to develop a novel, pharmacist-directed, pain management service. The primary goals of the service were to work collaboratively with providers to optimize pain management, decrease opioid associated adverse effects, and improve overall patient satisfaction scores.

The pharmacy pain management service (PPMS) is comprised of 3 full time clinical pharmacists who are available 7 days a week, 10 hours a day to all adult acute care medical/surgical floors and the intermediate intensive care unit. Daily functions include response to prescriber-initiated “pain management per pharmacy” consults and “opioid stewardship.” When consulted, pharmacists complete a medication review and a verbalized pain assessment to detail patient specific factors that may impact therapy. PPMS pharmacists make recommendations to optimize analgesic pharmacotherapy while minimizing the risks of medication-induced side effects. Opioid stewardship entails review of electronic reports to identify patients with elevated risk for opioid associated adverse events, inadequately controlled pain, and high risk opioid therapies. Interventions are made when necessary. The PPMS also provides ongoing staff education, responds to formulary requests, and reviews/develops pain order sets.

At 9 months post implementation, 1,335 interventions were documented with an estimated indirect cost savings of $1,622,449. Of these interventions, 81% were the result of prescriber consults, with opioid stewardship comprising the remaining 19%. The acceptance rate of pharmacist recommendations was 88%. Consults covered a wide variety of pain complaints including chronic pain, peri-operative pain, sickle-cell crisis, cancer pain, and end of life pain. Decreased use of “high dose” parenteral hydromorphone and transdermal fentanyl and a decrease in opioid associated Rapid Response Team/Code Blue events were noted on retrospective review. Despite decreased use of opioid medications, patient satisfaction scores increased.

Our pharmacist-directed pain management service is one step in an initiative to increase access to healthcare providers with specialized education in pain management, improve patient outcomes, and decrease the burden of pain on the healthcare system as a whole. Pharmacists are uniquely positioned to direct and monitor analgesic pharmacotherapy. By using skills unique to their discipline, our pharmacists have been able to show significant cost savings associated with avoidance of adverse medication events while improving pain control as assessed through increased patient satisfaction scores.