PHAMACI56’ 4ole IN PAIN FREE PROGRAM · non-formulary items (KPK) ... Patients referred to Pain...
Transcript of PHAMACI56’ 4ole IN PAIN FREE PROGRAM · non-formulary items (KPK) ... Patients referred to Pain...
PHARMACISTS’ Role IN
PAIN FREE PROGRAM
Pharmaceutical Services Programme
Ministry of Health Malaysia
INTRODUCTION
Every year, ten millions of people around the world suffer
from pain without treatment.
In year 2001, the Joint Commission Accreditation
Standards for Health Care Organization adopted pain
management standards stating that every patient has a
right to have pain assessed and treated.
A multidisciplinary healthcare team will be the best
approach to achieve optimum outcome in pain
management.
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National Pharmaceutical Regulatory Agency (NPRA), Malaysia had stated
1,575 ADR cases were reported in year 2017 involving 14 types of NSAIDs
Skin and subcutaneous
disorders 48%
eye disorders 29%
respiratory, thoracic and mediastinal
disorders 10%
systemic and local administration site
reactions 7%
gastrointestinal disorders
6%
Source : Noorleen Mohamed Ali, NPRA
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INTRODUCTION
A retrospective review at Saint John’s Health Center, California
from August 2006 to July 2007 showed that Pain Management
Pharmacist’s discharge facilitation had saved cost
approximately $97,200 for the 12-month period.
Pharmacist has an essential role to safeguard cost effectiveness
and safety of pain medications.
Pharmaceutical Services Programme, MOH has showed
support on PFH initiatives by providing individualized pain
medication therapy management to patients.
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Aims of the TOT for Pharmacist
To guide pharmacists in Ministry of Health:
Establish Pain MTM services at their facilities
Ensure quality of Pain MTM services by setting up
standard methods of performing various tasks in
the services.
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Roles of Pharmacists in Pain
Management:Technical Clinical
• Obtain, store and secure pain
medicines
• Distribute
• Prepare & Dispense Medicinal
Products
• Provide Effective Pain Medication
Therapy Management (MTM) via
assessing patients’ health status
(continuous/ follow-up) and
medication history
managing patients’ medication
therapy.
monitoring patients’ progress and
outcomes
providing information about
medicines and other health related
issues
General
• Plan and implement continuing professional development strategies to improve
current and future performance.
• Contribute to improve effectiveness of the health-care system and public health
“Joint FIP / WHO Guidelines on GPP : Standards for Quality of Pharmacy Services”Pain MTM Services6
Consist medications from hospital formulary especially
needed for Pain Free Hospital (PFH)
Prepare list of essential medications needed for PFH inclusive
controlled items (A/KK & A*), psychotropic substances and
non-formulary items (KPK)
Coordinate with relevant pharmacist (Sub-store OPD &
Logistics) – usage, quota, slow moving, short expiry and import
permit items
Ensure sufficient stock availability & establish contingency
plans during shortages of medicines and for purchases in
emergencies
Proper storage condition – controlled substances, fridge
items
1. Obtain, store & secure
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Common Medications (Examples)
Paracetamol
1g/100ml injection
NSAIDs
Non-selective
Selective COX2 Inhibitor
Celecoxib 200mg cap
Etoricoxib 90mg & 120mg
tab
Parecoxib 40mg injection
Opioids
Weak opioids
Strong opioids
Aq Morphine 10mg/5ml
Morphine SR 10mg, 30mg tab
Oxynorm 5mg & 10mg cap
Oxycontin 10mg & 20mg tab
Oxycodone 10mg/ml
injection
Targin 5/2.5, 10/5, 20/10
Buprenorphine patch
5mcg/hr, 10mcg/hr
*Methadone 5mg/ml syr
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Common Medications (Examples)
Adjuncts –
Neuropathy pain
TCA
Nortriptyline 10mg &
25mg tab (KPK)
Amitriptyline
Anticonvulsants
Gabapentin 100mg
Pregabalin 75mg &
150mg cap
SNRI
Duloxetine 30mg &
60mg tab
PCA and Epidural
Topical application
Lignocaine patch
Ketotop, Acustop
Gels and creams
Combination items
available at GP &
community pharmacy
Panadeine, Panadeine
Forte
Ultracet
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Distribution – assures reliability and safety ofmedicine
Preparation
Conducted in appropriate technique especially
sterile to ensure efficacy & safety of products [IV
admixture for Pain Control Analgesia (PCA)]
Extemporaneous should be done according
formulation MOH Extemporaneous Formulary &
proper reference [Syrup Morphine]
2. Distribute, Prepare & Dispense
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Dispensing – Good Dispensing Practice should be practiced
Institutions that do not have pain clinic, may need to find a
mechanism to differentiate pain management prescription
and ordinary prescription
Quantity of medication supply depending on the
indication (e.g PCM)
Suggest: stamp “PAIN FP” on the prescription
Ensure patient receives enough medication at pharmacy
(outpatient/ satellite/ bedside at ward)
2. Distribute, Prepare & Dispense
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Psychotropic Substance
Pain management especially for pain score 7 and above,
need to use psychotropic substance
Psychotropic substance have risk of misuse and abuse.
Procurement, storage & dispensing of these group of
medication strictly should comply with Dangerous
Drug 1952 & Psychotropic Regulations 1989.
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Medication Requiring Special
Approval
These medications are:
Listed in MOH Formulary
NOT registered in Malaysia
Registered in Malaysia BUT off label indication such as
Syrup Methadone indication for detoxification
NOT in MOH Formulary such as Ultracet ®
[Tramadol37.5mg/ Paracetamol 325mg & Oxycodone Oral
Solution]
Require Director General of MOH or Senior
Director of Pharmaceutical Services Programme
approvalPain MTM Services14
Medication Requiring Special
Approval
Off label indication medication need get consent from
patient/ caregiver
For further detail can refer to Garis Panduan Permohonan
Memperolehi dan Menggunakan Ubat-ubatan yang
Memerlukan Kelulusan Khas Pengarah Kesihatan (KPK) /
Pengarah Kanan Perkhidmatan Farmasi (PKPF); Borang
BPF/103-KPK01 (Pindaan 4.0) and Borang BPF/103-KPK01S.
Accessible at www.pharmacy.gov.my; garispanduan.
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ROLE OF PHARMACIST IN PAIN
MANAGEMENT
CLINICAL ASPECT: Pain Medication
Therapy Management Services
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Pain Medication Therapy Management
A specialized pharmacy service
Provide by trained pharmacist
At MOH facilities including hospitals and health clinics
which implement Pain as 5th Vital Sign
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Objectives of Pharmacy Pain MTM
Services
To optimize pain therapy (controlled/reduce pain)
by recommending individualized pain regimen
To minimize adverse events and medication
errors by reviewing patients’ past and current
medications
To counsel patients on appropriate use of pain
medications and to increase patients’ understanding on
their medications.
To collaborate and to provide information to
healthcare providers on pain medications.
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Pain MTM Services
Ambulatory Setting
Pain MTM Clinic
Pre- AnaestheticMTM Clinic
Medication Counseling
(Pain)
Inpatient Settings
APS/ Multidisciplinary PainTeam Round
Medication Counseling
(Pain)
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Pain MTM Service in Ambulatory &
Inpatient setting
* General Pain
Counseling : Service
option for pharmacy
that have limitations to
operate Pain MTM
Counseling
1. Pain MTM Clinic
Scope of Service
• Patients recruited in this clinic are patients who are referred by pain specialist/ Family Medicine Specialist (FMS) or selected by pharmacist at the clinic.
Location of service
• Operate in the Pain Clinic area during the clinic days. But not a mandatory requirement and depends on the local facility set up.
Manpower Requirement
• At least one trained pharmacist shall be on duty during clinic operating hours
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1. Newly started on analgesics & adjuvants (first time seen by pain specialist)
2. Therapeutic goals not achieved with current pain
medication regimen
3. Chronic pain requiring long term use of pain medication
and regular monitoring
4. Patients referred to Pain MTM Clinic with specific criteria will be included
a) Changes in pain medication regimen
b) Eperiencing side effects or complications due to their pain medications
c) On strong opioids therapy
d) Poor understanding on pain medication regimen
Pain MTM Clinic: Patient selection
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Pain MTM Clinic
Medication Education & counseling
• Explain & enforce
• Treatment goal
• Detail of medication
• Side effect & precaution
• Storage
• Missed dose
• Round the clock Vs when necessary
• Follow up counseling
Pharmaceutical Review
• Identify
• Assess & intervene
• Drug related problem
• Identify available therapeutic alternative
• Formulate individualized action plan
• Address safety concern
Pharmacist Recommendation
• Based on
• Intensity of pain
• Desired outcome
• Drug related problem
• Availability & policy of medicine
• Collaborate with other HCP
• Any intervention should discuss with clinician
Discharge Patient
• Criteria discharge
• Transfer to other hospital
• Wean off pain medicine
• Achieved treatment goal & no other PCI
• Patient requested
• Defaulted follow up for 1 year
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2. Pre-Anaesthetic Clinic
Scope of Service
• The pharmacist will perform duties including preforming medication history taking and medication review, patient counselling and education about the use of medication prior to surgery.
Location of service
• Will be provided at the clinic during anaesthetic clinic day. But is not a mandatory requirement and depends on the local facility set up.
Manpower Requirement
• At least one trained pharmacist needed to provide this service in the Pre-Anaesthetic Clinic.
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3. Acute Pain Service (APS)/
Multidisciplinary Pain Team Round
Scope of Service
• Provided to patients who will reviewed during APS/ Multidisciplinary Pain Team Round on working days.
Manpower Requirement
• At least 1 pharmacist (preferably Pain MTM pharmacist).
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3. Acute Pain Service (APS)/
Multidisciplinary Pain Team Round
Documents (ward pharmacy
documentation)
CP1 – Medication History Taking
CP2 – Pharmacotherapy Review
CP3 – Clinical Pharmacy Report
Form
CP4 – Nota Rujukan Pesakit
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This service is applicable to both ambulatory and
inpatient settings of hospital or health clinic that has
implemented P5VS at their facility and unable to
provide specialized Pain MTM Services.
For documentation and workflow, please refer to
Garispanduan Kaunseling ubat-ubatan 2014 published by
the Pharmaceutical Services Programme, MOH.
4. Medication Counselling (Pain)
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Medication Counselling (Pain) :
Patient criteria for counselling
On long term
analgesics
Complex analgesic regimen
Multiple comor-bidities
Special
population
Poor under-
standing
Referred
from other
healthcare
facilities
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PHARMACY PAIN
MANAGEMENT GUIDELINES
Pharmaceutical Services Programme
Ministry of Health Malaysia
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Pharmacy Pain Management Guidelines
First edition was in year 2016
Second edition in year 2018
Published by Pharmaceutical Services Programme,
MOH
Content : Pharmacy Pain Management Services can
provided in MOH facilities
These guidelines accessible at website :
www. pharmacy.gov.my – Publications
www. moh.gov.my – Publications
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TRAINING PROGRAMME FOR
PAIN PHARMACIST
Pharmaceutical Services Programme
Ministry of Health Malaysia
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Training Module For Pharmacist in
Pain Management
Pharmacist must undergo training to certify as pain
Pharmacist
at recognized training center
Hospital Raja Permaisuri Bainun, Ipoh
Hospital Sultan Ismail, Johor Bahru (in process)
2 weeks attachment
Teaching material
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REPORTING OF PAIN MTM
SERVICES
Pharmaceutical Services Programme
Ministry of Health Malaysia
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Letter from Pharmaceutical Services
Programme
KKM.600-34/3/11(25) Jld 4 dated
16th March 2018
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Pelaporan Aktiviti Pain Farmasi
Borang pengumpulan data bagi aktiviti Pain MTM yang dijalankan oleh pegawai Farmasi di hospital yang diiktirafsebagai Pain Free Hospital (mulai 2018)
Pegawai farmasi yang menjalankan aktiviti tersebut perlumerekod dan menyimpan data-data yang diperlukan seperti di dalam borang pelaporan setiap bulan bagi tahun semasa.
Laporan statistik dihantar oleh Ketua Pegawai Farmasi (KPF)/ Pegawai Farmasi yang menjaga (PF YM) ke Bahagian Amalan & Perkembangan Farmasi, KKM melalui Timbalan PengarahKesihatan Negeri (Farmasi) (TPKN(F) di setiap 3 bulan
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Pelaporan Aktiviti Pain Farmasi
Bagi Hospital Kuala Lumpur (HKL), Institut PerubatanRespiratori (IPR) dan Institut Kanser Negara (IKN), laporan PF dihantar ke Bahagian ini melalui KPF, KetuaJabatan Farmasi atau PF YM.
Bahagian Perkhidmatan Farmasi Negeri perlu menganalisisdan mengemukakan laporan statistik ini kepada Bahagianini seperti tarikh yang telah ditetapkan di atas.
Bahagian Amalan & Perkembangan Farmasi, KKM melaluicawangan Penjagaan Farmaseutikal akan menghantar data-data Ke Unit Kualiti (Pain Free Program/P5VS) BahagianPerkembangan Perubatan
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Pain MTM
Pelaporan Aktiviti Pain Medication Therapy Management (MTM)
Negeri : _____________
Tempoh/ Bulan : _____________
Ho
spit
al/ F
asi
liti
Bil. Pegawai
Farmasi1Klinik Pain MTM2
Kau
nse
lin
g s
ela
in d
i
klin
ik M
TM
(K
has
un
tuk
pain
man
agem
en
t)3 Bilangan Kes4
Bilangan
Pesakit di
kaunsel di
Klinik
Anaesthetik5
Ad
vers
e d
rug
Reacti
on
(A
DR
)6
Med
icati
on
Err
or
(ME
)7
Bil. Pesakita Bilangan Kaunselingb
Sepenuh M
asa
Separ
uh M
asa
Bar
ui
Pesa
kit S
usu
lan
ii
Opioidi
Antidepressant/
Anticonvulsant/
Other(s)ii
Acu
te P
ain S
erv
ice
(APS)
Multid
isci
plin
ary
Pai
n T
eam
Round
Jan – Mac Pada 10 April 2018
Jan – Jun Pada 10 Julai 2018
Jan – September Pada 10 Oktober 2018
Jan – Disember Pada 10 Januari 2019
Nota:
TPKN(F) akan menghantar borang ini ke Bahagian Perkhidmatan Farmasi, KKM
setiap 3 bulan
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AKNOWLEDGEMENT
This is an initiative by the Pain Pharmacy Committee of Pharmaceutical Services Programme, Ministry of Health Malaysia. Would like to express
our heartfelt gratitude the committee members of the reviewers, contributors and all those involved for
their valuable and constructive comments in the completion of this guideline.
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