PHAMACI56’ 4ole IN PAIN FREE PROGRAM Bebas...indication (e.g PCM) Suggest:stamp “PAINFP”on the prescription Ensure patient receives enough medication at pharmacy

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.

Pain MTM Services2

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

ROLE OF PHARMACIST IN PAIN

MANAGEMENT

TECHNICAL ASPECT

Pain MTM Services7

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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http://www.pharmacy.gov.my/

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

PAIN MTM SERVICES IN

AMBULATORY

Pain MTM Clinic

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 Workflow : Initial Visit

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Pain MTM Clinic Workflow : Subsequent Visit

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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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AMBULATORY

Pre-Anaesthetic Clinic

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.


• At least one trained pharmacist needed to provide this service in the Pre-Anaesthetic Clinic.

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2. Anaesthetic Clinic Work Flow

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INPATIENT

Acute Pain Service (APS)/

Multidisciplinary Pain Team Round

3. Acute Pain Service (APS)/


Scope of Service

• Provided to patients who will reviewed during APS/ Multidisciplinary Pain Team Round on working days.


• At least 1 pharmacist (preferably Pain MTM pharmacist).

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3. Acute Pain Service (APS)/


Documents (ward pharmacy

documentation)

CP1 – Medication History Taking

CP2 – Pharmacotherapy Review

CP3 – Clinical Pharmacy Report

Form

CP4 – Nota Rujukan Pesakit

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PAIN MTM SERVICES :

GENERAL

Medication Counselling (Pain)

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



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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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First Edition, 2016 Second Edition, 2018

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TRAINING PROGRAMME FOR

PAIN PHARMACIST



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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



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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

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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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Thank You

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