Cancer Pain

I noticed her the moment she walked into the pharmacy. She was small, at least 20 pounds under her ideal body weight. She had a thick sweater and a furry hat, not only to keep her warm, even though it was in the low 70's, but also to hide her hairless scalp. She had called ahead to make sure we had morphine in stock, letting us know that the chain store pharmacy she normally goes to did not have any. We are always hesitant when someone calls to ask if we have a specific controlled substance on hand; however, her voice and response to our questions immediately alleviated that concern. We said sure, bring the prescription and we will take a look at it.

Situations like this are not new to us. We are an outpatient pharmacy for a local community hospital. We frequently receive phone calls from patients unable to locate a medication in town or have had a disingenuous experience with one of the local big box pharmacies. We are the end of the line in town and if we are unable to resolve a prescription problem we contact the physician to for an alternative medication rather than return the prescription and dismiss the patient.

This particular patient was new to us so our technician gathered the appropriate information, completed a profile and entered the prescription into the computer. As with any new patient taking a controlled substance we do our “due diligence” to evaluate the authenticity of the prescription and the appropriateness of therapy. The prescription was written appropriately. Although it was a relatively large quantity of medication it was not unreasonable considering the indication and diagnosis. The prescribing medical oncologist practices out of a clinic less than a mile from our pharmacy and we see this type of prescription from this particular physician regularly.

After a review of our states Prescription Drug Monitoring Program (PDMP) we could find nothing wrong with her prescription. Her pain medication was prescribed by her oncologist and filled regularly at one of two different chain store pharmacies over the past three months. I did notice that she was only receiving short acting narcotic pain medication and no long acting pain therapy. I made a mental note to discuss this with the patient in the counseling session.

The prescription is now filled, paid and signed for and the technician asks the patient to meet the pharmacist over in the counseling area. As I approach the counter I am struck with her overwhelming sense of frustration with pharmacies in general, as well as her incredible feeling of relief that we are able to fill her prescription and also take time to counsel her. She explains that the pharmacy she has been using made her "feel like a drug-addict". She says this as she is taking her furry cap off of her shrinking bald head as if to prove to me that she really is a chemotherapy patient.

For me, this is a breakthrough moment. I appreciate the opportunity to explain that all of our patients get the same treatment, whether they are diagnosed with pain, high cholesterol, diabetes, or any other diagnosis treated with medications.

After a thorough discussion of this particular medication, I am convinced that she is using her pain medication appropriately and understands its usage. Next, I discussed that I noticed she was not using any long acting narcotic medications. She looked at me quizzically, so I went on to explain how patients with extended pain control needs will often be prescribed a long acting medication taken once or twice daily or a patch that is placed every two or three days. The patient will then use the short acting medication for the in between or breakthrough pain.

I like to draw a graph of time (x-axis) versus level of pain control (y-axis). It is easy to show that in this situation, a short acting medication will have multiple spikes over 24 hour, quickly breaking through the pain threshold to a high level, only to fall again within a couple hours down below the pain threshold. These spikes are associated with side effects. In this scenario, a patient needs to plan their day around making sure they always have pain medication with them. They may find that they are limited in their activities and outings due to inadequate pain control and may realize they are constantly looking at the clock to see if it is time for their next dose.

Next, I will draw what a long acting pain medication may look like on the graph. We have a long sloping curve that, over the course of 1-2 hours reaches the pain threshold and continues slightly above the threshold for 8 hours, then falls back below. On the graph it is easy to see that taking the short acting, breakthrough pain medication at strategic times along with a long acting medication may allow for an extended period of comfort with fewer medication related side effects. This process also allows for an increased quality of daily activity time.

Even though the patient had stated she was satisfied with her pain control regimen, in her three months of chemotherapy related pain control, she had never had this explained to her. She explained to me that with her current therapy, which is liquid and dosed every 3-4 hours, if she doesn’t wake up in the middle of the night to take a dose of her medication she will be in excruciating agony when she wakes up the next morning. She goes on to explain that even though she takes the medication every 3 to 4 hours, she regularly only gets 1.5 to 2 hours of reasonable pain control and needs to base her daily activities around her medication dosing.

This patient, in her nicest tiny voice, explains to me that her oncologist is fantastic with chemotherapy medication combinations; however, it was her opinion that he was too busy to explain her pain management. She actually apologized for her doctor.

I offered to call her physician to discuss the pain medication regimen further. She greatly appreciated the offer; however, she took many notes and stated she would be discussing the issue with her physician within the next couple days. She was very grateful for the information and thanked us for treating her like a human.