• Effect of Liposomal Bupivacaine (Exparel) on Length of Stay in Total Knee Replacement Surgery

      Wolk, Robert; Anderson, Seth; College of Pharmacy, The University of Arizona (The University of Arizona., 2018)
      Specific Aims Specific Aim #1: The primary outcomes of this study are to measure the length of stay (LOS), opioid use per 24 hour inpatient time period, and over all opioid rate in total knee replacement (TKA) patients who receive liposomal bupivacaine as compared to standard post-operative pain management protocol. Specific Aim #2: The second aim of this study is to analyze 30 day admissions between the two groups. Methods A Retrospective chart review was used to compare LOS and 24, 48, and 72 hour opioid use between the treatment group, liposomal bupivacaine and the control group consisting of Tucson Medical Center pain management protocol in patients who received a single TKR. Opioid use will be measured by postop 24-hour time intervals: 0-24, 25-48, and 49-72 hrs. All doses of opioids will be converted to oral morphine milligram equivalents (MME) using Tucson Medical Centers Equianalgesic dosing protocol. Non-normal continuous data was analyzed using the Wilcoxon Rank Sum test, normally distributed continuous data was analyzed using an independent t-test and categorical data was analyzed using a 𝜒2 test with the significance level set at 𝑎= 0.05. Main Results: The treatment group had a mean age of 70.7 (years) (SD=8.6), 25 females (50%), 31 right TKR (62%), and 34 surgeries performed by Dr Cohen (68%). The control group consisted of a mean age of 72 (years) (SD=9.4), 32 females (64%), 29 right TKR (58%), and 25 (50%) surgeries performed by Dr Cohen. (table 1) The treatment group had a mean LOS of 47.63 hrs (SD=18.8) vs 64.65 hrs (SD=23.0) (P<0.0001). in the control group. The average 0-24 opioid morphine milligram equivalents for the treatment group was 62.96 mg (SD=31.9) vs 99.00 mg (SD=60.3) (P=<0.001) in the control group . The average 25-48 opioid morphine milligram equivalents for the treatment group was 43.04 mg (SD=35.8) vs 73.04 mg (SD=46.2)(P=<0.001) in the control group . The average 25-48 opioid morphine milligram equivalents for the treatment group was 73.04 mg (SD=38.3) vs 51.06 mg (SD=39.1) (P=0.06) in the control group . Conclusions: Liposomal Bupivacaine was associated with a statically significant shortening of length of stay (47.63 hrs vs 64.65 hrs, P<0.0001) Liposomal Bupivacaine was associated with a statically significant lowering of opioid use over the first 24 and 48 hour inpatient stay (62.96 mg vs 99.0 mg, P=<0.001) Both Liposomal Bupivacaine and control groups had a non-significant difference in opioid use over 49-72 hour inpatient stay (43.3 mg vs 73.04 mg, P=0.06) There were a total of three readmissions, one in the liposomal bupivacaine group and two in the control group a non-significant difference (73.04 mg vs 51.06 mg , P=0.56) Liposomal bupivacaine group was associated with a statically significant lowering of rate (mg/hour) of opioid use over the entire length of stay (2.24 mg/hr vs 3.06 mg/hr, P=0.002)
    • The Efficacy of Self-Management Programs for Chronic Pain: A Preliminary Review

      Slack, Marion; Azaril, Kim; Billington, Taness; Garlick, Kelsey; College of Pharmacy, The University of Arizona (The University of Arizona., 2017)
      Objectives: To identify studies that have been conducted on pain self-management interventions to describe the strategies used in the treatment of pain Methods: Eligible studies were determined using a study inclusion-screening tool. To be eligible, studies needed to be randomized controlled trials comparing some type of self-management intervention to an alternative or usual care. Once determined to be eligible, selected studies were analyzed by two investigators using a consensus procedure and full article data extraction form which collected data on the study characteristics, patient characteristics, self-management strategies and relevant study outcomes. Results: The chronic pain management strategies from the 14 randomized controlled trials used in this study included: acupuncture, mobile based intervention, yoga, meditation/relaxation techniques, cupping therapy, musical therapy, cognitive behavioral therapy, physical therapy and self-management therapies. All studies showed a statistically significant reduction in pain from baseline, however, the effect size ranged from very small (0.02) to quite large (2.2). Conclusions: Most studies showed a meaningful reduction in pain, hence, a wide variety of self-management strategies are available for managing pain.
    • Evaluation of a Pain Outcome Measures Collection Program in an Interdisciplinary Pain Management Clinic

      Hoyer, Gifford; DiGiacomo, Mark N.; College of Pharmacy, The University of Arizona (The University of Arizona., 2006)
      The Southern Arizona Veterans Affairs Health Care System (SAVAHCS) Chronic Pain Rehabilitation Clinic (CPRC) is an interdisciplinary pain management team. The team consists of physicians, a psychologist, a kinesiotherapist, a nurse and a pharmacist, who work together, to manage pain. In order to monitor and improve the effectiveness of treatment at SAVAHCS CPRC, the team created a pain outcomes measure collection program. A pilot study of the pain outcomes data collection process was conducted. The purpose of this project was to evaluate the data collection procedure and identify areas for improvement. The program planned to collect outcomes data at a new patient education/orientation class using an intake questionnaire. After three months, a follow-up questionnaire was to be mailed to the patient. The patient would then return the questionnaire, by mail, to the clinic where responses would be entered into an electronic database. Eight items in the data collection process were recognized as needing improvement. Three of the most important items follow. (1) Mailing out questionnaires had a low response rate, which could be solved by administering the intake questionnaire during the pharmacist medication evaluation, and the follow-up questionnaire, 6 months later, during a provider appointment. (2) The investigational review board approval process took longer than anticipated but could be corrected through enforcement of a submission time line. (3) Data entry required a large amount of time but could be rectified through the use of volunteers. Overall, the data collection program could gather outcome measures, but procedural adjustments need to occur.
    • Evaluation of Adjunctive Analgesics to Reduce Pediatric IV Morphine Requirements of Patients Cared for in the Emergency Department

      Phan, Hanna; Menke, Meghan; Phan, Hanna; College of Pharmacy, The University of Arizona (The University of Arizona., 2016)
      Objectives: Pain management in the pediatric population is crucial when providing emergency medical care, as inadequate pain control is a significant cause of morbidity and mortality. The use of adjunctive therapy can potentially decrease opioid requirements, thereby reducing potential opioid related adverse effects. The purpose of this study was to evaluate the use of adjunctive therapy and impact on morphine dose requirements for pediatric pain management in the emergency department (ED). Methods: This study was an IRB approved retrospective review of pediatric patients ages 1 to 18 years, who received intravenous (IV) morphine therapy in the ED. Patients were excluded based on opioid-tolerance (using opioids prior to ED visit), diagnosis of sickle cell disease, and oncologic disorders. Data collection included baseline demographics, medical diagnoses and comorbidities, morphine total dose by weight, type, dose by weight and frequency of adjunctive analgesia agents, and pain scores. Results: The use of adjunctive analgesia in addition to morphine did not reduce the total morphine doses given, repeat morphine dose requirements, admission rates, or length of stay but did increase the time to a repeat dose of morphine. In those patients who received adjunctive analgesia before morphine, we saw a statistically significant decrease in the total amount of morphine received, total morphine doses given, repeat morphine dose requirements, and admission rates. Conclusions: In pediatric patients who require pain management in the ED, adjunctive analgesia should be given before morphine to reduce the amount of morphine required.
    • Evaluation of the Didactic Pain Management Curriculum at the University of Arizona College of Pharmacy

      Fankhauser, Martha; Draugalis, JoLaine; Goeller, Adrienne; Patel, Sushma; College of Pharmacy, The University of Arizona (The University of Arizona., 2007)
      Objectives: This study evaluated the didactic pain management curriculum from 2003 to 2006 at the University of Arizona College of Pharmacy in comparison to a compilation of current published standards. Methods: The study design was a utilization-focused evaluation conducted by two doctor of pharmacy candidates. The eleven domains of cognitive and affective abilities used for analysis were compiled from the International Association for the Study of Pain (IASP) guidelines and from published expert-panel competencies in the American Journal of Pain Management (AJPM). These documents were chosen for comparison because they were created with the purpose of developing competent and proficient pharmacy clinicians. Results: The analysis revealed that the University of Arizona College of Pharmacy was unsuccessful in meeting the recommended standards for pain management competencies. Instruction in pain management was poorly integrated, incomplete, and sporadic throughout the coursework. Conclusions: Pain management was insufficiently addressed in coursework at the University of Arizona. Separating pain from other topics, integrating pain entirely into the therapeutics course, creating a course devoted to pain management, and/or fulfilling standards through a required clerkship may improve the current curriculum. The results of the assessment will be used to provide recommendations to improve the curriculum concerning pain management.
    • Self-management of Pain Among Pharmacy Students

      Slack, Marion; Hernandez, Carlos; Slack, Marion; College of Pharmacy, The University of Arizona (The University of Arizona., 2016)
      Objectives: The purpose of this study is to determine if pharmacy students are more likely to use pharmacological agents to manage pain and if men and women are equally likely to use pharmacological agents. Methods: Questionnaires were administered after a regularly scheduled class for first, second and third year pharmacy students. Data collected included a pain intensity rating, whether pain was acute or chronic, how the pain was managed (medication, exercise, etc.) and if pain interfered with activities. Results: A total of 218 students (41% men, 71% aged 19-25) participated; 70% reported acute pain, 16%, chronic pain, and 14%, no pain. Pain intensity was greater in the chronic pain group (5.8 ± 1.7) than in the acute pain group (5.0 ± 2.1; p = 0.028). Chronic pain respondents were more likely to use prescription NSAIDs, muscle relaxers, physical therapy, transdermal electrical nerve stimulation, steroid injections and beta blockers (p < 0.02). There were few differences between men and women; women used OTC NSAIDs and acetaminophen at higher rates than men (p < 0.02). Women also used two non-pharmacological strategies (changed position and relaxation) at higher levels than men (p < 0.02). Students with chronic pain reported more pain interference with daily and leisure activities (p < 0.005) and work (p = 0.003) than students in the acute pain group. Conclusions: Different strategies were used for pain management between acute and chronic pain participants, and also between both men and women. Students with chronic pain reported more interference with activities than those with acute pain.
    • Self-Management Strategies for Chronic Pain Reported in Population-Based Surveys: A Systematic Review

      Slack, Marion; Bemis, Lola; Harper, Bonita; Molla-Hosseini, Sima; College of Pharmacy, The University of Arizona (The University of Arizona., 2017)
      Objectives: The purpose of this systematic review was to identify the types of management strategies reported by individuals with chronic pain to manage chronic pain, the average number of strategies used, outcomes, and side effects. Methods: To be included in the systematic review, reports of population surveys of adult patients with chronic pain, as defined by the authors, had to be published in English, include chronic pain from any cause, and include information on the treatment strategies used by respondents. Search terms included “pain,” “self-care,” “self management,” “self treatment,” and “adult” and the search strategy included systematic searches of Pubmed, Embase, Cochrane Library, PsycINFO, CINAHL, Web of Science, International Pharmaceutical Abstracts, searches of reference lists, and citation searches as well as key websites such as the CDC and NIH. Results: A total of 13 study reports were identified. Sample size ranged from 103 to 4839; mean age ranged from 42 to 81 and 51 to 69% female. All reports included information on medications used to manage pain; 6 reported other medical strategies; 9 reported physical strategies; 6 reported psychological strategies; and 11 reported non- medical strategies. Only 4 studies reported some data on the number of strategies used; one study reported 23% used 6 or more medications, another reported 51% used 3 or more strategies. Six studies reported some type of outcome; including inadequate control of pain (40%) or good relief (87%), and 36% as effective in a third study. Few side effects were reported; two studies reported constipation, nausea and vomiting. Conclusions: Population-based surveys of chronic pain have identified a large number of strategies used to manage pain, however they provide little information on the average number of strategies used, the effectiveness of the strategies, or resulting side effects.
    • Self-reported Management of Back Pain by Community Dwelling Adults: A Systematic Review

      Slack, Marion; Martin, Jennifer; Azadbakht, Mostafa; Rahim, Rasoul; College of Pharmacy, The University of Arizona (The University of Arizona., 2018)
      Purpose: The purpose of this systematic review is to identify strategies that community dwelling adults use to manage chronic back pain. Methods: Studies were eligible for inclusion if the study participants were at least 18 years of age, and currently suffering from back pain and living in the community. Excluded were reports on individuals who were institutionalized. The articles had to be written in English language. We searched Pubmed, Embase, and conducted citation searches on identified articles. Two researchers independently reviewed studies for inclusion, and extracted data from identified studies. Any differences were resolved by consensus. Data were extracted on strategies used to manage pain and outcomes. Data were analyzed by constructing tables to report types of strategies used and outcomes. Main Results: A total of 1929 study reports were identified; 9 were included in the systematic review. The primary strategy to manage back pain was using medications. 5 studies reported the use of opioids. All studies except one reported the use of anti-inflammatories. Studies also reported the use of psychological strategies (e.g. coping strategies), physical strategies (e.g. exercise), and remedies (e.g. rest). Most studies were cross sectional, participants were 29-49 percent male, average age (31-66). All studies were of community dwelling adults. Conclusions Medication was the primary strategy used to manage back pain. Opioids, and anti-inflammatories were the most common classes of medications. The most commonly reported non-medication strategy were physical strategies. Only limited information was provided on all the other strategies.
    • Strategies Used by Pharmacists for the Self-Management of Acute and Chronic Pain: An On-Line Survey

      Slack, Marion; Lee, Jeannie; Chavez, Ramon; Trinh, Daniel; Vergel de Dios, Daniel; College of Pharmacy, The University of Arizona (The University of Arizona., 2017)
      Objectives: Specific Aim 1: Pharmacist will use pharmacological pain self-management strategies over non- pharmacological strategies. Specific Aim 2: Pharmacist pain self-management strategies will differ based on whether or not the pharmacist has chronic pain. Specific Aim 3: Pharmacist pain self-management strategies will differ across age. Specific Aim 4: Pharmacist pain self-management strategies will differ across gender. Methods: A survey was sent to all pharmacists with an email address registered with the State Board of Pharmacy in a single Southwestern state. The survey asked about characteristics of pain, strategies for managing pain, outcomes, and demographics. The primary outcome was severity of pain after treatment. Results: Responses were received from 417 pharmacists; 219 reported acute, 206 reported chronic pain, and 55 reported no pain. The chronic pain group was more likely to have a disability with poor/fair health status (P<0.006) and to report higher levels of pain before treatment (6.9 versus 5.8). Both groups reported similar relief from all strategies (76% versus 78% ; P equals 0.397), but the chronic pain group reported higher levels of pain after treatment (3.2 versus 2.0), less confidence in pain management, and less satisfaction (P less than 0.004). Conclusions: Age and gender did not affect the use of specific pain management strategies or the amount of pain relief received from all strategies used by participants with either acute or chronic pain. However, participants with chronic pain had higher levels of pain before and after treatment.
    • Survey of Chronic Pain Specialists and Their Experiences with Pharmacies in Managing Chronic Pain

      Sredinski, Eric; Slack, Marion; Bricker, Bryce; Munson, Lisa; College of Pharmacy, The University of Arizona (The University of Arizona., 2011)
      OBJECTIVES: The purpose of this study was to survey prescribers who manage patients with chronic pain to evaluate how pharmacy services are perceived to affect patients’ quality of life. METHODS: Surveys were sent to prescribers who manage patients with chronic pain. Prescribers rated pharmacy services on a scale of 0 – 5 (0 being not important at all, and 5 being extremely important) to the quality of life of patients with chronic pain. RESULTS: Surveys were completed by 23 subjects. Prescribers ranked pharmacy services as follows: the pharmacy fills opioid prescriptions for all pain conditions (mean = 4.2; SD = 1.0), the patient is able to obtain the entire quantity of pain medication (mean = 4.1; SD = 1.5), the pharmacy treats the patient as dependent on, not addicted to opioids (mean = 3.9; SD = 1.6), the pharmacy collaborates with the prescriber to manage opiate therapy (mean = 3.9; SD = 1.5), the pharmacy stocks new and recently approved pain medications (mean = 3.8; SD = 1.1), the pharmacy provides the patient with information on adverse effects of pain medications (mean = 3.8; SD = 1.5), the pharmacy is able to use manufacturer co-pay cards to minimize out-of-pocket costs (mean = 3.5; SD = 1.7), the patient can have prescriptions delivered to their home (mean = 2.1; SD = 1.8) and the patient can obtain a prescription without having to wait a specified time period determined by their pharmacy (mean = 1.8; SD = 1.5). CONCLUSION: Prescribers in this study felt that certain pharmacy services are very important in the treatment of patients with chronic pain. Pharmacies may improve patients’ quality of life in the management of their chronic pain by providing these services.
    • Topical Pain Relief Management: Assessment of Patient Satisfaction with A Novel Compound Containing at Least Ketoprofen

      Draugalis, JoLaine R.; Reed, Thomas C.; Mance, Jessie Jean; College of Pharmacy, The University of Arizona (The University of Arizona., 2006)
      Objectives: To assess perceived efficacy and patient satisfaction at a single point in time during a course of therapy with a compounded topical formulation containing at least ketoprofen in an anhydrous gel base. Methods: Patients aged 18 and older, currently using one of the topical pain relief compounds of interest obtained from Reed’s Compounding Pharmacy in Tucson, Arizona were recruited and then interviewed (in person or by telephone) for this study. Data collected during patient interviews were recorded on a form designed solely for the purposes of this study. Interview questions pertained to the nature of the participant’s pain, their assessment of their pain both before treatment with the medication of interest and at the time of the interview, frequency and duration of patient use of the pain relief gel, disclosure of any other pain relief medications the patient was using at the time, and their overall satisfaction with the medication. Results: Interviews were conducted with a total of 50 patients with chronic pain conditions representing several different etiologies and anatomical locations. The average pain assessment score at the time of the interview (representing perceived patient pain after use of the topical pain relief compound) was significantly lower than the average before treatment pain assessment score (p<0.001). After treatment with the gel had commenced, perceived pain scores dropped by average of 3.56 units (SD 2.28), or 44%. Increased frequency of application of the topical pain relief gel was not associated with greater pain relief or changes in overall patient satisfaction with the product. A longer duration of use of the topical pain relief was also not associated with greater pain relief or overall patient satisfaction with the product. Whether or not a patient utilized other pain relief medication(s) while undergoing treatment with the topical pain relief gel had no bearing on the assessment of their pain either before use of the gel or at the time of interview. The average overall patient satisfaction with the topical pain relief compound was rated at 6.6 out of a possible 10 units (SD 3.13). Thirty-six patients (72%) rated their satisfaction with the topical medication of interest with a satisfaction score of ≥ 6, 10 patients (20%) rated their satisfaction with a score of 10 (completely satisfied), and 6 patients (12%) rated their satisfaction with a score of 0 (not at all satisfied). It was observed that the lower the perceived pain assessment score at the time of the interview (after using the gel), the greater the patient satisfaction with the product. Additionally, patients were observed to be more satisfied with the product if the difference between their perceived pain assessment scores (before and after) was greater (i.e.: greater patient satisfaction with greater pain relief). Conclusions: Treatment of chronic pain with a topical pain relief compound containing at least ketoprofen in an anhydrous gel base is associated with patient satisfaction and perceived analgesic benefits. During the one-time interview, most patients reported a significant improvement in their pain relief, and the great majority of patients were very satisfied with the compounded topical treatment they received from Reed’s Compounding Pharmacy.