The challenge of pain management obviously extends to all parts of the health care system. What can managed care pharmacies do to improve this situation without becoming an additional pain?

Some pharmacy benefit managers (PBMs) monitor for high prescribers of control drugs. Although this practice may seem useful in attempting to prevent abuse, it also may discourage physicians from adequately treating their chronic-pain patients, especially those with terminal conditions. Efforts could be directed toward adopting or developing algorithms for pain and symptom management, and then educating clinicians with the use of these algorithms. The Health Plan Employer Data and Information Set and the National Committee for Quality Assurance have no standards regarding pain management. The development of quality standards in this area might help to raise the level of care for patients. These accrediting agencies should be encouraged to address the issue of adequately managing pain.

Our pharmacy organizations and schools of pharmacy should set a priority on educating pharmacists and other health professionals on pain assessment and management. PBMs and managed care organizations (MCOs) can also take a leading role in this effort by educating their prescribers and staffs through training programs and newsletters. MCOs could investigate the development of specialized pain clinic.

In addition to educating health professionals, the task of educating patients should not be overlooked. The more patients understand their pain, the better they will be able to manage it. We should explore partnerships with industry in developing, distributing, and utilizing patient education tools. MCOs can take the lead in developing educational programs for their community pharmacy networks. The community pharmacist is an accessible member of the health care system and could be of great value in managing this patient population.

We also must not overlook the public policy arena. We must pay close attention to the effect that state and federal laws and regulations may have on the delivery of treatment. Will the requirement of triplicate prescription blanks for Schedule II medications have an adverse effect on treatment by making prescribers fearful of having "big brother" knock on the door for assumed over-prescribing of pain medication? This past year, the proposed federal legislation to prohibit the use of controlled drugs in assisted suicide would surely have had a negative impact on the treatment of pain. Legislative initiatives must be analyzed for their unintended negative consequences. Pharmacists must be politically active in protecting their patients' rights to quality health care.

Even though more than one-third of the population is estimated to have a chronic pain condition, pain is still not well understood and often is mistreated. The direct cost of pain management has not been significant enough to hit the radar screens of most PBMs.

Energy has been put into the management of diseases such as diabetes, asthma, and hyperlipidemia. Although these disease states deserve our attention, we should remember that half the people with nonmalignant pain conditions feel their pain was inadequately treated. We should remember that these patients were in pain 80% of the time and in severe pain 30% of the time. We should make every effort to expand our knowledge of pain management and to provide the programs needed for other pharmacists and health professionals, as well as patients, to expand their knowledge.

David B. Moore, M.P.A.
Assistant Professor
School of Pharmacy
University of Maryland
Director of Pharmacy Services
Spring Grove Hospital Center
Baltimore, Maryland