IASP Curriculum on Pain For Pharmacy

Task Force Members: Chris Herndon, Roger Knaggs, Scott Strassels, Phil Wiffen (Chair)

Every pharmacist should be able to assess and manage pain, with particular understanding of pharmacological interventions for the management of pain. This curriculum is intended to provide the optimal level of education on pain and its management for entry level pharmacists throughout the world.

Outline Summary

Introduction
Principles
Objectives
Curriculum Content Outline
 I. Multidimensional Nature of Pain
 II. Pain Assessment and Measurement
 III. Management of Pain
 IV. Clinical Conditions
References

Introduction

Everybody experiences pain at some time, whether it is as the result of a sporting injury or persistent back pain. Pain is a multidimensional and complex phenomenon that requires comprehensive and regular assessment along with effective management. An interprofessional approach to assessment and management is required for the best patient outcomes. All professionals need to serve as advocates for the person in pain and ensure that pain treatment is based on ethical principles and evidence-based standards and guidelines.

Pharmacists have a vital role in ensuring safe and effective pain management as they are often the first point of contact for patients seeking non-prescription analgesics and advice regarding prescription analgesics. Also, pharmacists have frequent contact with patients experiencing pain in hospital and hospice settings.

The central role and responsibility of the pharmacist in helping to manage patients' pain are in promoting the safe and effective use of analgesic medicines. In order to do this they are required to have an understanding of the epidemiology of pain, pain mechanisms, frequently encountered pain conditions, variables which influence the patients' perception of and response to pain, valid and reliable methods of clinical pain assessment, and both pharmacological and non-pharmacological methods for pain relief.

Principles

The following principles guide the pain curriculum for the entry level pharmacist:

  1. Pain is multidimensional with psychosocial, behavioral, spiritual, and genetic variables.
  2. Patients have the right to safe and effective pain control.
  3. Pharmacists are an integral and accountable part of the care of the patient in pain.

Objectives

Pharmacists, upon completion of a program following this recommended curriculum, will be able to:

  1. Describe neurophysiology as it relates to normal sensory transmission
  2. Explain the pathogenesis of pain including hyperalgesia, peripheral sensitization, and central sensitization
  3. Classify pain syndromes (e.g. acute, subacute, chronic, nociceptive, neuropathic, inflammatory, central, or mixed)
  4. Ensure current and sufficient understanding of the pharmacology of non-opioid, adjuvant, and opioid analgesics at a level to provide instruction to the patient and other members of the health care team.
  5. Recommend evidence based utilization of rational pharmacotherapy for individual pain syndromes based on patient-specific, drug-specific, and environmental-specific variables.
  6. Contribute to the assessment of the patient in pain including unidimensional and multidimensional rating scales, patient interview, and limited physical assessment where applicable.
  7. Participate in the goal setting and ongoing education of the patient with pain.
  8. Provide assistance in the overall risk avoidance plan when opiates and opioids are used for pain control.
  9. Understand and assume an active role within the interdisciplinary team

Curriculum Content Outline

I. Multidimensional Nature of Pain

A. Definitions of Pain

  1. Types of pain
    1. Acute pain
    2. Persistent (chronic) pain
    3. Cancer pain
    4. Breakthrough or episodic pain
  2. International Association for the Study of Pain nomenclature
  3. Hyperalgesia, hypoesthesia, paresthesia, allodynia, analgesia, dysesthesia, hyperesthesia

B. Epidemiology of pain

  1. Overview of acute, cancer pain and persistent non-cancer pain

C. Multidimensional nature of pain (physical, psychological, spiritual, emotional) and ‘total' pain

D. Impact of unrelieved pain

  1. Physiological benefit of acute pain and lack of survival benefit for persistent pain
  2. Influence on inadequate acute pain relief on the development of persistent pain
  3. Impact of persistent cancer and non-cancer pain on:
    1. The individual (e.g., physical, psychosocial, spiritual, vocational, socioeconomic)
    2. The family (e.g., roles, relationships, psychological concerns, socioeconomic factors)
    3. Society (e.g., cost, lost productivity)

E. Pain as a public health issue

F. Neuroanatomy relevant to pain

  1. Transduction
    1. Primary afferent neurons (types, characteristics, excitation, terminal sites)
  2. Transmission
    1. Temporal summation, peripheral sensitization, central sensitization
    2. Excitatory pre- and post-synaptic potentials
    3. Second-order neurons and synaptic junctions
    4. Rexed Laminae, physiology and synaptic transmission in the dorsal horn
  3. Modulation
    1. Descending excitatory and inhibitory pathways
    2. Excitatory and inhibitory neurotransmitters
  4. Perception
    1. Thalamocortical pain signaling
  5. Theories of pain control
    1. Gate control theory
    2. Neuroplasticity and the neuromatrix

G. Pharmacology of pain transmission

  1. Peripheral mechanisms
    1. Chemical mediators and relevant neurotransmitters
    2. Inflammatory mediators
    3. Voltage dependent calcium and sodium channels
  2. Central mechanisms
    1. Role of NMDA in wind-up
  3. Relationship and differences between pain etiology (i.e. tissue damage, inflammation, nerve damage)
  4. Receptors and neurotransmitters and in pain modulation
    1. Alpha-2 adrenoceptor
    2. Relevant 5-HT receptors
    3. Opioid receptor subtypes and associated physiologic effects
      1. Opioid agonist, partial-agonist, agonist-antagonist, antagonists
      2. Pharmacokinetics and pharmacodynamics based on receptor affinities
      3. Opioid induced hyperalgesia
    4. Cannabinoid receptors

H. Psychological and Behavioral Issues

  1. Influence of affective, cognitive, behavioral processes on pain and biopsychosocial model of pain
  2. Effects of co-morbid psychiatric (depression, anxiety, PTSD, bipolar disorder etc.) and psychological (personality disorders) diagnoses on pain perception
  3. Effects of emotional and spiritual stressors on pain perception
  4. Pain catastrophizing, dual-dependence, secondary gain, and self-efficacy
  5. Dependence, tolerance, addiction and pseudoaddiction
  6. Substance abuse, substance misuse, aberrant drug behaviors
  7. Drug adherence/persistence and risk of aberrant behaviors
  8. Iatrogenic drug addiction
  9. Disparities in the expression and management of pain
  10. Effect of culture on pain
  11. Health care provider influence on pain, compliance/persistence with treatments and outcomes

I. Ethical Issues

  1. Pain as a violation of ethical principles
  2. Pain relief as a human right
  3. Concepts of opioid physical dependence, psychological dependence, pseudo-addiction, tolerance and habituation
  4. Awareness of consensus definitions issued by pain organisations
  5. Opioid availability as a human rights imperative
  6. Controversies around euthanasia and pain relief in terminally ill patients and terminal sedation
  7. Controversies surrounding physician-assisted dying

J. Research design

  1. Design and evaluation of analgesic drug studies
    1. Randomized controlled trials, Placebo vs. active comparator, Availability of rescue medication
    2. Other designs (cohort, case-control, etc)
    3. Efficacy vs effectiveness trials
    4. Non-pain endpoints (including SPID and related time-intensity composites, physical, psychological and social functioning, HRQL, costs, adverse events)
    5. Placebo response in clinical trials
  2. Methodology recommended by IMMPACT and other consensus statements or guidelines
  3. Time-pain intensity composites (SPID, etc), especially in acute pain studies
  4. Clinically important compared with statistically significant differences

II. Pain Assessment and Measurement

A. Measurement, quantification and recording of pain intensity and pain relief

B. Pain assessment tools

  1. Uni-dimensional pain scales; such as visual analogue scales, numerical ratings scales, categorical rating scales
  2. Multi-dimensional pain scales; such as McGill Pain Questionnaire, Brief Pain Inventory, Neuropathic Pain Scale and PainDetect
  3. Assessment of psychological co-morbidities; Hospital Anxiety and Depression Scale; Beck Depression Inventory
  4. Assessment of generic health-related quality of life (SF-36, etc) – broad instruments that typically include questions on pain
    1. Assessment of psychological co-morbidities; Hospital Anxiety and Depression Scale; Beck Depression Inventory
    2. Improved activity and functional goals as outcome measures
    3. Self-report; such as use of a pain diary and problems associated with observer assessed pain
    4. Pain as an adverse event

III. Management of Pain

A. Pharmacological interventions for pain

  1. The following areas to be covered for each drug or drug class:
    • Mechanism of pharmacological action
    • Relevant medicinal chemistry
    • Relevant pharmaceutics and formulation science
    • Routes of administration
    • Pharmacokinetics, including mechanisms of toxicity where appropriate
    • Adverse effects and their management
    • Drug-Drug interactions
    • Clinical uses
    • Patient counseling regarding appropriate use
      1. Acetaminophen (paracetamol)
      2. Non-steroidal anti-inflammatory drugs (NSAIDs) and coxibs
      3. Opioids
      4. Opioid substitution therapy
      5. Tramadol and tapentadol: similarities and differences to opioids
      6. Antidepressants
      7. Anti-epileptics
      8. 5-HT1 agonists (triptans)
      9. Local anesthetics
      10. Capsaicin
  2. Extemporaneous compounding of dosage forms not available commercially, including uncommon routes of administration and special need formulations
    1. Assurance of efficacy, effectiveness, bioavailability, safety, stability of extemporaneously compounded drugs
  3. Drug storage requirements for stability and safety
  4. Knowledge of legislation regarding controlled substances including their legal and safe destruction
  5. Variability of opioid availability for oral and parenteral use due to legal and regulatory restrictions in some countries

B. Interventional pain management

  1. Anesthetic nerve blocks
  2. Neurolytic blocks
  3. Intrathecal drug delivery

C. Nonpharmacological Approaches to Pain

  1. Physical therapy
  2. Psychological and behavioral strategies
  3. Acupuncture and acupressure
  4. Neuromodulation devices, including TENS and spinal cord stimulation
  5. Surgical interventions
  6. Herbal and alternative/complementary therapies

D. Multimodal and interprofessional pain management

  1. Interdisciplinary approach to pain management
    1. Role of different professions
  2. Role of pain clinics and pain management centers
  3. Palliative care and role of hospices
  4. Unique contribution of pharmacist
  5. Role of the specialist pharmacist
    1. teaching
    2. research
    3. clinical activities
    4. advocacy
  6. World Health Organization, International Narcotics Control Board and other government or organization clinical evidence-based pain management guidelines

IV. Clinical Conditions

A. Acute pain

  1. Post-operative pain
  2. Acute pain due to acute medical illness, such as myocardial infarction
  3. Pain in hematological diseases; sickle cell disease and hemophilia

B. Persistent non-cancer pain

  1. Musculoskeletal pain, including low back pain, osteoarthritis and inflammatory arthritis
  2. Headache, including tension headache, migraine, medication overuse headache
  3. Neuropathic pain – relevant examples including diabetic peripheral neuropathy, post herpetic neuralgia and acute herpes zoster infection, trigeminal neuralgia, phantom limb pain, and central pain syndromes (e.g. post-stroke pain and multiple sclerosis)

C. Cancer pain

D. HIV-associated pain

E. Painful OTC conditions, including counselling about appropriate analgesic use

F. Choice of analgesia in renal and hepatic impairment

G. Pain and analgesia at the extremes of age (neonates, children and the elderly)

H. Pain and analgesia in pregnancy, labour and breast-feeding

I. Pain management in individuals with history of substance abuse, misuse or addiction

References

American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older P. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. Aug 2009;57(8):1331-1346.

Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. Feb 2009;10(2):113-130.

Dworkin RH, O'Connor AB, Audette J, et al. Recommendations for the pharmacological management of neuropathic pain: an overview and literature update. Mayo Clin Proc. Mar 2010;85(3 Suppl):S3-14.

Vadalouca A, Raptis E, Moka E, et al. Pharmacological Treatment of Neuropathic Cancer Pain: A Comprehensive Review of the Current Literature. Pain Pract. 2011 Jul 2 doi: 10.1111/j.1533-2500.2011.00485.x.

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