Julie L Cunningham, PharmD, BCPP, DPLA
Associate Chief Pharmacy Officer Clinical Practice & Research
Mayo Medical Center
Since the declaration of the opioid epidemic as a public national health crisis in 2017 there has been an emphasis on opioid stewardship practice in health care. Many health care systems have developed formal opioid stewardship programs to provide best practice guidance and metrics to analyze prescribing as well as harm reduction practices. However, opioid related deaths continue to rise, leading to the need to better identify and treat opioid use disorder (OUD) with appropriate medications and develop management processes.1
The new 2022 CDC Opioid Prescribing guidelines have provided welcomed updates from the 2016 version, but also present increased complexities to the management of patients with pain and substance use disorders, often co-occurring.2,3 While this highlights the need for pharmacists trained with pain management expertise, it also demonstrates the overlap in roles of behavioral health and pain management pharmacists. Specifically, the new guidelines recommend an evaluation for patients starting and continuing opioids for risk of opioid harm and for providers to “use validated tools or consult with behavioral specialists to screen for and assess mental health and substance use disorders”.3
In the past several years, several new structured continuing education or certificate programs have been developed to meet the educational gap for pharmacists in pain management. Examples include focused pain management training programs such as the American Pharmacist Association (APhA) Pain Institute, certificates (American Society of Health System Pharmacists (ASHP) Pain Management and Opioid Stewardship), as well as other training programs. Pharmacists board certified in psychiatric practice are often accepting pain management and opioid stewardship roles to fulfill practice needs. As of July 11, 2022 there are 31 PGY2 Palliative Care/Pain Management pharmacy residency programs with 33 residency positions and one pain management fellowship program. There are 23 Palliative Care/Pain Management PGY2 programs participating in the 2023 ASHP residency match compared to 54 Psychiatric PGY2 programs.4
It is unlikely roles with clear distinctions between pain management and behavioral health exist, necessitating the inclusion of experiences and education that cross both areas within each residency training program. The ASHP overview for PYG2 in pain management and palliative care include substance use experiences as an optional experience.5 Similarly, pain management experiences are listed as selected learning experiences in the ASHP overview for PYG2 Psychiatric residencies.6 Learning opportunities in areas of chronic pain management, OUD clinics, as well as the emergency department where medications for OUD are initiated, would provide valuable training experiences in both PGY2 programs.
Soon, the Board of Pharmacy Specialties (BPS) will evaluate the proposed addition of a pain management pharmaceutical board certification. Seven petitioning organizations have been participating in the formal process of authoring this petition for BPS consideration. In addition to AAPP, other organizations include the American College of Clinical Pharmacy (ACCP), APhA, American Society of Consultant Pharmacists (ASCP), ASHP, Hematology/Oncology Pharmacy Association (HOPA), and Society of Pain and Palliative Care Pharmacists (SPPCP). This is the largest number of petitioning organizations for a new board certification to date and reflects the intersection of pain with many other disease states. The process for a new specialty to gain board certification approval involves a detailed application process outlining specific criterion. The criterion documents outline the need, demand, the business decision, and the education and training currently developed to support the specialty need. Additional fundamental elements of the petition outline the core definition of the pain management pharmacist role, a literature review of pharmacist contributions in the field, and a survey of both interested pharmacists practicing in the role and employers describing the need for the specialty by projecting current and anticipated positions. Results from the survey indicate significant employment needs for pharmacists with pain management expertise as an area of growth.
If the pain management board certification is approved, it is anticipated many pharmacists in these areas of practice may seek board certification in both psychiatric practice and pain management. In order to best position our residents for these new roles, it is essential to identify learning experiences, quality improvement initiatives, and research projects with an emphasis on OUD, chronic pain, and opioid stewardship. And in the spirit of collaboration that will be needed going forward, it could be useful to collaborate with current pain PGY2 programs for their recommendations on what psychiatric PGY2 residents would find most meaningful in their learning experiences. In return, they would also benefit from our knowledge of what psychiatric learning experiences would be pertinent for a PGY2 pain experience.