Preventing Polypharmacy in the Pain Clinic

Drug interactions and polypharmacy play a large role in the opioid epidemic, says Elizabeth Casserly, PharmD, RPh, BCPS, a clinical pharmacist in Cleveland Clinic’s Department of Pain Management.

“By themselves, and in low doses, opioids are typically safe,” she says. “But when patients are on several opioids, at high doses, or in combination with benzodiazepines [anxiety drugs], they have a much higher risk of overdose and death.”

Both opioids and benzodiazepines reduce respiratory rate and are addicting. Their potency multiplies when they’re combined.

“It’s not that physicians knowingly prescribe these drugs together,” says Dr. Casserly. “It happens inadvertently — like when a patient fills a benzodiazepine prescription from their primary doctor and, maybe months later, fills an opioid prescription from their pain doctor. We really can’t control what drugs patients already have at home.”

How opioids became the go-to pain drug

Pain physicians can help prevent potentially deadly polypharmacy interactions by not prescribing opioids when possible, says Dr. Casserly. Here she lists opioid alternatives for treating the three primary types of pain.

1. For nerve pain. “We commonly prescribe tricyclic antidepressants (TCAs), such as amitriptyline, nortriptyline and desipramine,” says Dr. Casserly. “Other options include, serotonin-norepinephrine reuptake inhibitors (SNRIs), such as duloxetine, or anticonvulsants, such as gabapentin or pregabalin.” Neuropathy is difficult to treat, and some medications can take weeks to have an effect. In the meantime, lidocaine cream or patches can give short-term relief, she says.
2. For inflammatory pain. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, ibuprofen, naproxen and meloxicam, can dull pain caused by inflammation. However, NSAIDs can cause complications for patients who have cardiovascular disease, kidney disease or gastrointestinal bleeding. For these patients, rubbing NSAID gels onto a painful joint is may be safer than swallowing NSAIDs, says Dr. Casserly.
3. For musculoskeletal pain. Dr. Casserly recommends heat, stretching and physical therapy and possible use of short term muscle relaxants.

Physicians and pharmacists working together

Staying apprised of pain medications and all of their usage considerations may seem overwhelming. That’s why more physicians are relying on pharmacists for ongoing guidance — and even collaboration on treatment decisions.

“Now with the opioid epidemic, more hospitals are looking to pharmacists for treatment alternatives,” says Dr. Casserly. “It’s good for all physicians to have a working relationship with a pharmacist for help with problem solving and exploring pharmaceutical options.”

Adding a Staff Pharmacist to the Chronic Pain Clinic

She’s a first at Cleveland Clinic. Elizabeth Casserly, PharmD, RPh, BCPS, is a clinical pharmacist who works alongside physicians in Cleveland Clinic’s Department of Pain Management.

“I’m integrated into the Chronic Pain Clinic,” says Dr. Casserly. “I collaborate with physicians to determine the best treatment for each patient. If medication is needed, we discuss interactions and other considerations to identify the best drug.”

More medical centers have begun adding pharmacists to their clinical teams, she notes.

Pain Management Department Chairman Richard W. Rosenquist, MD, stresses the importance of Dr. Casserly’s role, saying, “I have been working with a clinical pharmacist in my pain practice for 22 years and have found them to be invaluable members of the team.”