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Understanding How CMM Can Improve Chronic Pain Management

In a recent article, we discussed some benefits of comprehensive medication management (CMM). While CMM can help many patient populations, one that stands to benefit significantly is chronic pain patients. That's why it's not surprising to see literature and research drawing correlations — direct or indirect — between CMM and improving chronic pain management.

As a report from the CMM in Primary Care Research Team notes, there are five essential functions required to facilitate consistency in the delivery of CMM. They are as follows:

1. Collect and analyze information

The clinical pharmacist assures the collection of the necessary subjective and objective information about the patient and is responsible for analyzing information in order to understand the relevant medical/medication history and clinical status of the patient.

2. Assess the information and formulate a medication therapy problem list 

The clinical pharmacist assesses the information collected and formulates a problem list consisting of the patient's active medical problems and medication therapy problems in order to prioritize recommendations to optimize medication use and achieve clinical goals.

3. Develop the care plan

The clinical pharmacist develops an individualized, evidence-based care plan in collaboration with the healthcare team and the patient or caregiver.

4. Implement the care plan

The clinical pharmacist implements the care plan in collaboration with the healthcare team and the patient or caregiver.

5. Follow up and monitor

The clinical pharmacist provides ongoing follow-up and monitoring to optimize the care plan and identify and resolve medication therapy problems, with the goal of optimizing medication use and improving outcomes.

Leveraging Comprehensive Medication Management Functions

Let's examine how clinicians and other thought leaders believe each of these functions can support efforts to deliver enhanced and safer care for chronic pain patients.

Collect and analyze information — As a British Journal of Anaesthesia article notes, … the chronic pain experience is shaped by a myriad of biomedical, psychosocial (e.g. patients' beliefs, expectations, and mood), and [behavioral] factors (e.g. context, responses by significant others). Assessing each of these three domains through a comprehensive evaluation of the person with chronic pain is essential for treatment decisions and to facilitate optimal outcomes. This evaluation should include a thorough patient history (including a review of a patient's medication history) and medical evaluation and a brief screening interview where the patient's [behavior] can be observed. Further assessment to address questions identified during the initial evaluation will guide decisions as to what additional assessments, if any, may be appropriate. 

Assess the information and formulate a medication therapy problem list — In a Podiatry Today column on drug interactions and opioids, author Dr. Robert Smith, a podiatrist practicing in Florida, writes, A meticulous drug history should include an examination of the patient's prescribed medications as well as over-the-counter drugs, herbal supplements, illicit drugs, cigarettes and alcohol consumption. One should understand the general principles of drug interactions and appreciate the major risks for interactions for the principal drug classes prescribed.

Develop the care plan — A column in The Hill written by Dr. Beth Darnall, a clinical professor at Stanford University School of Medicine, Department of Anesthesiology and Perioperative Medicine, notes, We must remember, however, that opioid limits alone do not constitute a pain care plan, nor do blanket opioid limits appreciate the individual differences across patients who live with pain. Over the past 15 years, the absence of patient-centered pain care contributed to an over-focus on prescribing opioids. … To be truly effective, our pain treatment programs and our policies should be evidence-based. They should be patient-centered. And, as one component of patient-centeredness, they should be accessible to those who need them.

Implement the care plan — An Advisory Board blog on improving chronic pain management to reduce chronic utilization, highlights the success of a care plan program from HealthPartners and Regions Hospital, noting that as part of the program, A multidisciplinary committee meets monthly to create new care plans and determine the appropriateness of care plan patient candidates referred by other providers in the system. Each care plan lays out clear guidelines for patients and providers regarding when and where it is appropriate for the patient to receive narcotics or other frequently requested treatments. The care plans are also written at an eighth-grade reading level and discussed with the patient to ensure full patient comprehension of the plan. 

Follow Up and Monitor — As an article in the American Journal of Managed Care notes, Monitoring adherence, or the accuracy and consistency with which a patient follows the pharmacological regimen, is an important aspect of a chronic pain management plan. Nonadherence could include taking too much of the prescribed medication, diverting medication to other individuals, self-medicating with unprescribed or illegal drugs, or taking medication inconsistently.

Furthermore, as a Medscape article discussing the findings of a survey of patients about their patient experience at a pain center summarizes, When it comes to the satisfaction of patients with chronic pain, patient care coordination is what matters most.

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