This study reported the changes of interventions by CP in the pain management of outpatients with cancer in a prescription cycle for the first time. We designed a prospective, case-by-case self-control study and found that CP played totally different roles in different stages of patients' medication in a prescription period.
On the first interview, the highest frequency of interventions was suggestions for adverse drug reactions (47%), corresponding to the pain control improved significantly from 7 to 3 and sleep, mood and daily activities related to pain also showed a similar trend. In the initial stage of medication, the drug worked quickly and the main problem is the adverse drug reactions. In particular, some common adverse reactions of opioids, like nausea, vomiting and dizziness, often occur in the early stage of medication, and then gradually tolerated. Therefore, when CP followed up the patients for the first time on the 7th day of medication, the most frequent of intervention is the guidance of the adverse drug reactions.
Seven days later, we set the second interview. Unexpectedly, the pain, sleep, mood and daily activities related to it changed, which became deteriorated, although statistically significant. It may be due to, first, drug tolerance, which needs increasing the dose to achieve analgesic effect. Second, many patients are in the advanced stage of the disease and the pain aggravated rapidly. Finally, poor medication compliance may be due to adverse drug reactions. Thus CP suggested the patients for a visit for further treatment (51%), prescribing new drug, adjusting the dosage or conducting further examinations.
Pain is a devastating symptom of cancer that affects the quality of life of patients. Despite the development of novel analgesics and updated pain guidelines, cancer pain remains undermanaged. Inadequate cancer pain management in the outpatient setting can be attributed to barriers on different levels, related to health care professionals, patients, and the health care system [5–7]. Particularly in the outpatient setting, health professionals are unable to monitor pain and provide adequate follow-up [8].
Recommendations to overcome barriers include a multidisciplinary approach that promotes collaboration between different health professionals and ongoing assessment of pain with regular follow-up appointments [9]. Educational interventions for patients may improve the success of pain management. Effective pain control mandates multidisciplinary interventions from interprofessional teams.
Many studies had shown that clinical pharmacists play an active role in the treatment of cancer pain. Gagnon evaluated the contributions of a clinical pharmacist in a palliative radiotherapy clinic, and found CP played a key role in holistic patient assessment and optimization of pharmacologic therapy, with pain improving at week 1 and week 4[10]. Liu evaluated the participation by the pharmacist in the cancer pain management team and found a marked reduction in most of the drug-related problems and a statistically significant change in pain score during the 4 visits, which indicated that pharmacists play an active role [11]. The study mainly intervened in prescription and doctor, and the whole period was short, 4 days. John Valgus described a pharmacist-led, interdisciplinary method in a cancer clinic and found that pharmacists participated in 78% of patient consultation and symptom scores including pain improved [12]. Chen found a Clinical Pharmacist-Led Guidance Team significantly improved standardization, efficiency, and efficacy of cancer pain therapy in China [13]. Wang found clinical pharmacist-led medication education resulted in improved pain control in patients with cancer [14]. These studies have proved the necessity of clinical pharmacists participating in the treatment of cancer pain, which can bring benefits to patients. However, they did not show specific interventions in one prescription period for outpatients with cancer pain.
In fact, many outpatients with cancer pain need to be closely monitored, especially for opioid-naïve patients, patients converting from one opioid to another, patients using high dosage of opioids, elderly patients, patients with liver and kidney dysfunction and poor tolerance of adverse reactions, and patients using several kinds of analgesics. There is an urgent to know how to manage these outpatients with cancer pain, educating them, monitoring the outcome, treating analgesic adverse effects, and providing guidance for further treatment. Based on a 15-days prescription cycle, this study described the different interventions of CP at different time for the first time, combined with the changes of pain score, better first and then worse. It is suggested that the interventions by CP were combined with the pain control.
The patient’s knowledge about analgesics greatly improved after treatment, which may be due to the education of CP, who send patients drug cards when prescribing drugs, and introduced the pharmacological characteristics, usage, precautions and adverse reactions of drugs when following-up, which could improve the knowledge of patients. It still reflects the role of pharmacist interventions. Yan Wang found that patients got greater knowledge in pharmacist-education group compared with control group [15].
This study has several limitations: 1) the small sample size drawn from a single clinic; a large-scale and multicenter study would be necessary to generalize the study findings; 2) more follow-up should be designed, such as every three days.