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Pain Management Content in Curricula of U.S. Schools of Pharmacy Rubina M. Singh and Susan L. Wyant

Objectives: To identify individuals in schools of pharmacy in the United States who are responsible for covering the topic of pain management in courses for doctor of pharmacy students and to describe how and at what depth pain management is covered in pharmacy school curricula. Design: One-time qualitative assessment. Setting: Schools of pharmacy in the United States. Participants: Twenty-eight faculty members with the rank of professor, associate professor, or assistant professor who had been employed in their current positions for at least 2 years and who were directly involved in preparing and teaching didactic courses that address pain management. Intervention: In-depth telephone interviews. Main Outcome Measures: Qualitative responses to open-ended interview questions. Results: While pain management was included in the curricula of all 28 schools of pharmacy, it was generally covered in a fragmented way, usually as part of presentations on diseases with pain as a prominent feature (e.g., cancer pain addressed during oncology lectures) or as part of discussions of analgesics. Only two schools offered stand-alone courses in pain management, and both of those courses were electives that were taken by an average of 15 students per year. Three-fourths of respondents believed that pain was being given too little emphasis in their schools’ curricula. Palliative care and the use of medications in the treatment of cancer pain was not presented in a standardized manner, and respondents were unsure of how the subject was covered in pharmacy law classes. Instruction about the diagnosis of pain, patient assessment, and physical examination was reported as “minimal” by most respondents. Respondents perceived a need for a single, complete reference and teaching resource that would address the entire spectrum of pain management as it applies to pharmacy. Conclusion: The topic of pain management is poorly presented and inadequately developed in the curricula of many U.S. schools of pharmacy.

Keywords: Pharmacy education, pharmacy school curricula, pain management, clinical therapeutics, laws and regulations. J Am Pharm Assoc. 2003;43:34–40.

Proper pain management has been a concern among patients and health care professionals for many years. As a result of efforts by the American Pain Society and the subsequent addition of pain treatment to standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 2001, pain has become, in essence, a “fifth vital sign” in many health care settings.1 Despite reports of pain-focused pharmaceutical care services,2–6 studies of practicing pharmacists have generally shown an inadequate level of knowledge about the therapeutics of pain management7 and the laws and regulations governing the use of opioid analgesics.8 These deficiencies impede access to needed medicaReceived November 14, 2002, and in revised form December 2, 2002. Accepted for publication December 13, 2002. Rubina M. Singh, PharmD, is project director, Pain Management Partnership, American Pharmaceutical Association, Washington, D.C. Susan L. Wyant, PharmD, is president, The Dominion Group, Vienna, Va. Correspondence: Rubina M. Singh, PharmD, American Pharmaceutical Association, 2215 Constitution Avenue, NW, Washington, DC 20037. Fax: 202-783-2351. E-mail: [email protected] See related article on page 81.

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tions by patients with acute, chronic, and cancer pain and leave the pharmacist poorly prepared to assume the role of medication expert on the health care team. Curricula at all schools of pharmacy in the United States have been revamped in the last 10 years as a result of the move to a new accreditation standard for the doctor of pharmacy (PharmD) degree.9 One study completed after most schools had revised their curricula indicated that management of headaches was not covered extensively in either required or elective courses at most schools of pharmacy in the United States.10 However, given recent concerns about pain management and media coverage about the limited availability of opioids in community pharmacies in parts of New York City,11 this topic may be assuming a more prominent role in the education of pharmacy students than it held in the past.

Objectives The objectives of this study were to identify individuals in schools of pharmacy in the United States who are responsible for

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covering the topic of pain management in courses for PharmD students and to describe how and at what depth pain management is covered in pharmacy school curricula.

Methods In fall 2001 administration and/or staff members at the 82 schools of pharmacy that were then operating in the United States were contacted in an attempt to identify individuals who met the following criteria: held the rank of professor, associate professor, or assistant professor in the school of pharmacy; had been employed in their current position for at least 2 years; and were directly involved in preparing and teaching didactic courses that address pain management. Based on the information received, 82 faculty members, one at each school, were contacted by telephone, fax, and/or e-mail in an effort to identify those willing to participate in a telephone interview. If no response was received, faculty members were contacted two more times. Faculty members who agreed to participate were contacted in October 2001 and interviewed by The Dominion Group, an unbiased market research organization based in Vienna, Va. Participants were engaged in in-depth discussions during which they were first asked to comment about the context in which pain management is discussed in courses for PharmD students, the rationale for including or not including pain management coursework in the current curriculum, and their opinion about the relative importance of pain management in the pharmacy curriculum. Participants were then asked about future plans at their school of pharmacy for modifying the current approach to the topic of pain management and to identify areas in which the American Pharmaceutical Association (APhA) could assist in curriculum or subject matter development. For some interview questions, interviewees were provided with response scales (e.g., from 1 to 10) or semantic differential responses (e.g., too much, too little, just right), while other items were open-ended. Because this study was primarily qualitative in design, no statistical analysis of data was appropriate.

Results A total of 28 pharmacy school faculty members met the criteria for study participation and agreed to be interviewed about pain management. These faculty members had been in their current positions for an average of 8 years (range, 2–24 years), with 11 participants having 5 years or less in their current position and 10 participants having between 5 and 10 years in their current position. Participants reported an average of 433 students in their pharmacy schools (range, 160–1,200 students). A majority of schools (17 of 28; 61%) had between 200 and 400 students. Most (23 of 28; 82%) offered only the PharmD degree, and one-half (14 of 28)

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offered PharmD degrees to nonresident students (i.e., those enrolled in “external” degree programs in which licensed pharmacists holding baccalaureate degrees in pharmacy can earn PharmD degrees without becoming full-time resident students). Respondents reported that only three of the schools (11%) had faculty members with special expertise in pain. One faculty member at each of two schools was a specialist in pain management, and a faculty member at a third school was active in both pain research and ongoing care of patients in a pain clinic.

Current Curricula Content The topic of pain management was included as part of the coursework of all 28 schools. However, among most of the schools the topic was addressed in general terms and presented in a rather fragmented manner without coordination or oversight from the respective curriculum committees. Nearly all faculty respondents indicated that their responsibility for teaching pain management was “self-appointed” and a result of their personal interest in the topic. Faculty interviewed at all 28 schools reported that the topic of pain management is usually incorporated into a broader course of study or instruction module, rather than in a stand-alone course. Some students received additional training in pain management during clinical rotations. Only 2 of the 28 schools (7%) offered a stand-alone course in pain management, and in each case, the course was an elective taken by an average of 15 students per academic year. Most frequently, interviewees reported that pain management was first discussed in the therapeutics or pharmacotherapy sequence, which most commonly was taken in the students’ third professional year. An almost equal number of schools reported that pain was a component of the oncology module. In most cases, pain was a special interest of individual faculty members. Instructors most frequently mentioned that pain management was integrated into their courses because “it wasn’t being covered anywhere else.” Across all years of study, several other courses/modules incorporated pain management at some level: Disease state management. Geriatrics. Neurophysiology. Nonprescription medications. Ethics. Clinical rotations. As reflected by its inclusion when professors were personally interested in the subject, instruction in pain management was typically not mandated by the school. Instructors frequently mentioned that integrating pain management as one component of broader study modules was necessary because insufficient time exists in the schedule for a stand-alone course and insufficient materials and information exist to teach a stand-alone course. Although a majority of the instructors interviewed believed that additional time was needed for the topic of pain management,

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nearly all supported doing so by incorporating pain management into a broader course topic rather than through establishment of separate courses. Typical comments included: I think that pain management has to be taught as part of another course because pain is a very abstract idea and too difficult to deal with outside the context of how it relates to certain disease states. I think it is more practical to address pain management this way; I think the students can grasp the issues more easily. Our curriculum committee has set things up with broad strokes. All the coursework is approached by therapeutic area, such as central nervous system, cardiovascular, renal, and so on. It is left up to each instructor as to what diseases we want to cover indepth within our section. Each instructor develops his or her own focus on pain. But the overall topic of pain management is not integrated by the curriculum committee. There is no oversight. There has been a big push within pharmacy education in the last 5 years to integrate all topics within the framework of curriculum organized around disease state management. Pain management would be addressed as part of disease state management wherever appropriate. We utilize a “distributive curriculum.” We don’t teach any standalone courses in the traditional sense. For example, we don’t teach cardiac care as a stand-alone. Cardiac care would be covered as it relates to many therapeutic areas. Pain management is a part of the presentation of multiple disease states. We consider pain as a symptom, not a disease state. The faculty is responsible for the coursework content, but there is supposed to be oversight by the department chair or the curriculum committee.

The module into which pain management is incorporated necessarily affects the philosophy of pain management conveyed to the students, and this can easily result in a skewed presentation that is somewhat biased toward that faculty member’s area of practice interest. For example, when pain management was taught as part of oncology modules, only the aspects of pain management dealing with malignant pain, hospice care, and end-of-life issues were thoroughly discussed. Concerns regarding addiction potential and maximum daily dose were downplayed, as they are less important within the context of end-of-life care. However, the principles of pain management in oncology patients do not adequately convey concepts of appropriate pain management in other situations. In the absence of curriculum coordination or oversight, most schools did not have any measures in place to present a broader and more balanced introduction to pain management. Generally, instructors reported little, if any, communication between faculty members about what aspects of pain management they were including in their coursework. As a result of operating within this vacuum, instructors generally had no knowledge of what was being addressed in pain management outside their own courses or which other faculty members were addressing the topic.

Perceptions of Im portance of Pain Content Of the 28 respondents, 21 (75%) believed that “too little”

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emphasis was being given to the topic of pain management. Because pain has emerged as a national health issue, respondents indicated that the numbers of didactic and practical hours allocated to pain in their curricula were incommensurate with the amount of time that pharmacists will deal with this patient care issue over the span of their careers. Respondents also observed that some curricula may “shy away” from devoting more time to pain management topics because, as one person said, “Pain is a subjective disease state that is difficult to teach in the abstract—other disease states are easier to quantify.” Two faculty members made the following observations: Pain is the most common complaint that brings patients to physicians. For every disease state, pain is the one element of disease that responds best to drug treatment. For example, all cancer pain can be treated with drugs successfully. We focus on curative treatments because they are more exciting, have more glamour and glitz. Pain management receives far too little attention, particularly considering it is one of the top three disease states that pharmacists will deal with, both in terms of number of complaints and number of prescriptions filled.

The seven remaining participants thought that the level of attention directed toward pain management is “appropriate,” given that across-the-board time constraints have equally “whittled down all other formal didactic subjects to bare bones as well.” Compared with other topics that are covered in therapeutics courses, the interviewees rated pain management 5.1 on a scale of 1 (least important) to 10 (most important). Other comments offered by participants about the level of importance placed on the topic of pain management included: We don’t spend anywhere enough time on this issue. [Pain management] is a topic that pharmacists will face in every aspect of their careers; it is a universal factor. Whether the student goes into a community pharmacy or [becomes] a hospital pharmacist—wherever they go, pain management is an active area of concern. We aren’t doing enough to equip them for this area. I know from my own experience and the feedback I get from my students who are [in clerkships] now that questions about pain management are the most frequently asked questions. We know we need to spend more time on it, but there’s just too much to cover already. We have [paid] way too little attention to pain management. Other than what I cover in a 2-hour lecture, I don’t know what the students are exposed to about pain management. I think that a lot of the faculty just hope that the students will pick it up in their clinical rotations. In the overall picture, I suppose we have an appropriate amount of time for pain management. I can easily see how I could use more time for pain, but then something else would have to be cut. So, it is a balancing act of trying to include at least a little bit of everything.

As an indication of the level of emphasis placed on pain topics in their current curricula, participants estimated that across all courses/years of study, an average of 9 total didactic hours were

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Table 1. Time Devoted to Pain Management in All Years of Pharmacy School Curricula

Total Didactic Hours Devoted to Pain Management 1–5

No. of Schools (n = 28) 11

6–10

8

11–15

9

Mean no. of hours (range)

9 hours (20 minutes–15 hours)

devoted to this subject (see Table 1). Although this number of hours has remained unchanged over the years, approximately twothirds of participants expected, or were hopeful, that the amount of time allocated to pain management topics would increase in the future. One-quarter of participants expected pain management coursework to increase by at least 3 didactic hours in the near future, and 4 respondents expected to offer pain management as a stand-alone elective course.

Pain M anagem ent Topics in Curricula No standardized approach was evident in the way pain management was organized within courses in the pharmacy school curricula. The subject matter was often categorized or subdivided into multiple “layers” that were determined primarily by the slant or philosophy of the specific module or course (e.g., pharmacology versus clinical management; oncology, neurology, or orthopedics). Most commonly, participants mentioned that pain management was categorized as follows: Acute versus chronic pain. Therapeutic area or disease state. Type of treatment or medications being studied. Type of pain commonly present in disease of interest. Practice setting relevant to course (e.g., long-term care, hospice, home care). The concept of palliative care was generally introduced as part of discussions about cancer pain, which was often covered in oncology modules. Only three (11%) respondents indicated that they offered a stand-alone elective course in palliative care. When pain was taught in a separate course, teaching responsibilities for palliative care were multidisciplinary in nature, often involving the chaplain service, social workers, physicians, and attorneys, in addition to pharmacy faculty. Otherwise, the teaching responsibility for addressing the concept of palliative care fell to the faculty member teaching the broader course of study into which the topic was incorporated. The time devoted to palliative care topics ranged from a 20minute lecture at schools with “only enough time to barely introduce the concept” to a 3-credit elective course featuring 35 hours of lecture. In curricula in which time permitted a more in-depth discussion about palliative care, the focus was often on ethical

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concerns at the end of life, when a cure is not possible. As one participant observed, “We may have to go above recommended amounts [of analgesics] to make patients comfortable. If one can do nothing at the end but make patients comfortable, that’s okay.” The focal points of palliative care discussions included the following: Pain should be aggressively approached, with no upper limit on dose. Emphasis on autonomy of patient choice and discussion of euthanasia. Identification of therapeutic goals. How to manage/prevent adverse effects of pain medications. Dispelling addiction fears. Alternative options to traditional therapies—“use of last ditch efforts and novel therapies.”

Specific Aspects of Pain M anagem ent Coursew ork Participants reported that in their coursework on pain management, treatment of pain and other clinical aspects of pain were the most common focal points of their discussions. Instruction about the diagnosis of pain, patient assessment, and physical examination was reported to be “minimal” by most respondents. Differentiating among types of pain was often limited to, for example, distinguishing the pain of osteoarthritis from that of rheumatoid arthritis. Some instructors reported that students needed a better scientific basis for understanding the neurophysiology and pathophysiology of pain, but that the scope and time constraints of their courses precluded inclusion of these topics in pain management discussions. All instructors reported that they included a discussion of prescription drugs, particularly opioids, in their pain management courses. Over-the-counter (OTC) products were discussed in detail at other points in the pharmacy school curricula, and just one-half of respondents indicated that they personally included a discussion about OTC analgesics (primarily nonsteroidal anti-inflammatory agents) in their pain coursework. Some instructors also discussed nonpharmacologic therapies (e.g., heat, cold, biofeedback), herbal products, and alternative therapies (e.g., acupuncture, hypnosis). Because respondents typically taught only one disease type, organ system, or class of medications (e.g., rheumatology, oncology, or nonprescription medications), students may have received instruction about all or most types of analgesics somewhere in the curriculum. But these responses indicate that the presentations are not necessarily coordinated since they occur in different lectures or courses. Physical dependence and addiction were typically addressed within the context of the therapeutics and/or oncology modules. Faculty respondents reported that the focus of discussions about physical dependence and addiction generally centered on two objectives: educating students about how to recognize, as opposed to manage, the addicted patient; and reversing misperceptions

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about the relationship between chronic pain treatment and addiction that can create obstacles to effective pain management. Typical comments included the following: I try to point out that it is wrong to assume that addiction always occurs with use of opioids and that patients in pain rarely get addicted. I always caution against using the word “addiction.” I go into this in great detail. I want students to recognize behaviors that should be reported to the patient’s physician. I also introduce the concept of contracting, which is a collaborative effort between one pharmacist and one physician in order to effectively treat pain and yet reduce the likelihood of abuse. Pain Assessm ent in Physical Exam ination Courses

Although five (18%) faculty members were certain that pain assessment was not covered in courses on physical assessment, many were uncertain about those courses’ content. Most remaining participants had the perception that pain was only “superficially” covered in their curriculum’s physical examination course and that pain assessment was taught only as it related to range of motion and/or severity. Students were briefly taught tactics for eliciting a pain history from a patient. Pharmacy-specific resources for teaching pain assessment are lacking, the faculty members said. Most available literature is written for medical or nursing students, leaving pharmacy faculty to write their own cases. Respondents indicated that pharmacy-specific case studies, integrated with active role-playing/hands-on experience, should focus on effective patient interview methods, including use of visual analog scales/pain survey instruments, and address management/counseling of uncooperative patients who demonstrate the potential to abuse pain medications. Other helpful resources would include videotape presentations, electronic slide decks, and information on a palliative/qualitative region severity approach to pain. Concept of Pain as a Fifth Vital Sign

Of the 28 instructors, 20 (71%) were familiar with the concept of pain as a fifth vital sign when the research presented here was conducted in October 2001. JCAHO had included increased pain parameters, education, and documentation requirements in its standards at the beginning of 2001.1 The faculty members familiar with pain as a fifth vital sign held a positive view of this new recognition of the importance of pain because it means pain will be taken more seriously by and be more visible to busy health care professionals. Those individuals had incorporated the concept into their coursework and noted that their patient care institutions had incorporated the concept into admission forms.

Supplem ental Educational Resources When asked what reference materials/sources they found particularly helpful in preparing their lectures on pain management,

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nearly all surveyed instructors complained about the lack of complete texts on pain management for pharmacists. Instructors must generally adapt for pharmacy the best of what they find in nursing or medical school texts. Most instructors believed it would be beneficial to them and to their students to have one complete source that would address the entire spectrum of pain management as it applies to pharmacy. Because instructors are “borrowing” materials from other fields, most reported information gaps in all areas of pain and pharmacists’ role in its management. The National Institutes of Health, the Agency for Healthcare Research and Quality, the World Health Organization, and the American Pain Society were most commonly mentioned by faculty members as sources of instructional information. The nursing text by McCaffery and Pasero12 was cited by many participants as the best resource for pain management courses, although one respondent found it deficient in that it includes no dosing information. Several others mentioned the Pharmacotherapy: A Pathophysiologic Approach13 textbook as their main resource. The vast majority of pharmacy schools (26 of 28; 93%) offered clerkships or clinical rotations for pharmacy students to provide them with additional hands-on learning about pain management. Faculty members from the two schools currently without clinical rotation programs stated that they were in the process of starting programs. Pain-related rotations were commonly in oncology, general medicine, ambulatory care, orthopedic surgery, general surgery, hospice, and pain or headache clinic. Educational goals in rotations were similar to those in didactic coursework. Participants made several cogent comments: I think that all aspects of pain management are important. But I think that if we are able to make one stride forward, it’s having students and practitioners ask about pain. I don’t think that anyone even asks, “How’s your pain?” I want students to understand that pain can always be treated— and almost always effectively treated—with drugs. Pain treatment is part of the continuum of pharmacy practice. Understand how to initiate analgesics and taper treatment when appropriate. I want students to understand that it is unacceptable to let patients die in pain. Pharm acists as Facilitators of Appropriate Pain Managem ent

The inherent conflict between pharmacists’ roles in appropriate pain management and their stewardship of controlled substances was of concern to the faculty members. Although the participants acknowledged that “we really can’t get away from regulatory responsibilities,” most bristled at the notion of “pharmacists as drug police.” Rather, the faculty members emphasized, pharmacists have the duty as well as the ability to act as patient advocates, ensuring that pain is adequately controlled. Clinically, pharmacists have the responsibility to communicate patients’ response to pain to physicians and other health care providers. As one instructor commented, “Pharmacists tend to be obsessive and much too concerned

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about complying with regulations. I would rather teach students how to adequately manage patients’ pain.” Pharmacists have the ability to affect appropriate pain management both positively and negatively. As health care providers with, as one interviewee put it, “the best understanding of which drugs will work best for different types of pain,” pharmacists actively engaged as patient advocates have the ability to facilitate pain management through education of and communication with physicians and nurses and to provide patient counseling and education about pain management. However, many respondents observed that pharmacists often assume a passive role in patient care and are unwilling to intervene or communicate with physicians and nurses about patients’ pain. Some instructors reasoned that this passivity might result from a lack of proper pain management training and, therefore, a lack of professional confidence. Alternatively, some participants noted, pharmacists might lack the motivation to become “involved,” or their workloads in an era of pharmacist shortages might preclude expansion of services. Some respondents believed that the greatest impediment to appropriate pain management among pharmacists might lie in commonly held misperceptions about tolerance versus addiction and the ceiling doses for pain medications. Pharmacists not informed about these areas may stereotype patients and ultimately refuse to fill their prescriptions. In short, participating faculty members believed that pharmacists have not found their niche in helping to facilitate appropriate pain management and that they should be encouraged to take more active roles.

Future Expectations About Pain M anagem ent Coursew ork Reflecting on prior expressions of dissatisfaction with the amount of time devoted to the topic of pain management across pharmacy school curricula, instructors agreed that it is hardly possible to cover the topic adequately within the context of current coursework designs. They also said this attitude is reflected in the opinions of students, many of whom have complained to the faculty about the lack of availability of pain management electives. Students also frequently expressed the desire to learn more about the subject earlier in their course of study. As one instructor noted: Students continually bombard me with requests for more courses on pain. It’s something that they can identify with. After my last neurophysiology course, over half of the students told me that the time devoted to the topic wasn’t enough.

Participants were hopeful that ongoing curriculum evaluation and revision will identify means of incorporating more pain management coursework, but most had no immediate plans for modifying the current approach to pain management. Participants observed that the extent to which they are successful in eventually achieving a greater slant toward pain management topics will primarily depend on the extent to which the cause is championed

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by interested faculty, recruitment of additional staff with specialized training and interests in pain management, and the ability to incorporate additional pain management coursework into the curricula without sacrificing other core classes.

Discussion Based on the comments of this sample of faculty at 28 educational institutions, the approach to teaching pain management in the curricula of schools of pharmacy appears fragmented and unsupported by centralized curriculum planning. As a result, “core fundamentals” have not been developed, and comprehensive resources for pain management specific to the field of pharmacy do not exist. Most faculty members teaching various courses in which pain management topics overlap to some extent were delegated the responsibility of developing pain management lectures by default. The interviews indicated that faculty members with an interest in the topic of pain management take the lead in developing coursework as it applies to their specialty. There is little or no communication or coordination of pain management coverage between individual faculty members within the same school. Professors are generally unaware of how the topic is addressed in courses that they do not teach or in what manner the subject is covered in pharmacy law/ethics classes. Most participants were equally unaware of how pain is addressed in physical examination courses. Pharmacy schools stress a traditional pharmacology and therapeutics approach to the topic of pain management. Virtually all participants agreed that the emphasis given pain management in the current curricula is incommensurate with the level of clinical importance for the practicing pharmacist, particularly given that pain is one of the conditions that students expect to encounter frequently in pharmacy practice. Interestingly, given the recent media coverage devoted to opiates, and because virtually all students can identify with the subject of pain, students appear to be very interested in pain management and had expressed to interviewees a desire to learn more about the topic. Students may be exposed to pain management topics throughout their professional years of study, but these faculty members agreed that students are ready to learn about pain management from their first professional year of study forward. Participants generally thought that pharmacy students must understand that they are in a unique position to act as patient advocates for appropriate pain management, particularly with regard to chronic pain at the end of life. However, because the subject is often misunderstood or minimally addressed, pharmacists may be ill prepared to assume this role and may actually pose obstacles to, as opposed to acting as facilitators of, appropriate pain management as a result of their education about the need to guard against overuse of and fraudulent prescriptions for opioid analgesics. Better educational materials, prepared specifically for pharmacy students, are also needed. Medical publishers (including APhA)

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and pharmacy authors have a great opportunity to meet an unmet need, surveyed faculty noted, through the development of textbooks, casebooks, and Web-based materials on pain management, including legal, ethical, and clinical aspects.

Limitations Information collected in this study is qualitative in nature and was obtained from a relatively small number of respondents. The study findings, therefore, should be evaluated cautiously and not extrapolated to all schools of pharmacy in the United States or other countries. Given the general lack of attention given to pain management in these curricula, one might assume that other schools of pharmacy have even less coverage, but that conclusion is inappropriate given the nature of this sample. In addition, the information obtained in this survey constitutes the collective opinion of the faculty members interviewed. The accuracy of respondents’ perceptions about coverage of pain management was not independently verified, and some results indicated that respondents were not very familiar with other courses taught at their schools of pharmacy. Thus, respondents could have been biased, misinformed, or uninformed about the amount of lecture time devoted to pain management. Finally, while pharmacy students, graduates, and faculty will recognize that the amount of time devoted to pain management is small, no attempt was made to compare these findings with those for other diseases and conditions taught in pharmacy courses of these or other pharmacy schools in the United States or other countries.

Conclusion In the opinions of the pharmacy faculty members interviewed for this study, the topic of pain management is poorly presented and inadequately developed in the curricula of many U.S. schools of pharmacy. This situation could be rectified through the creation of more modules, rotations, and courses that focus specifically on the unique clinical, legal, and ethical aspects of acute, chronic, and

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cancer pain. In addition, better teaching materials are needed that are specific to the roles practicing pharmacists can play in pain management. The authors declare no conflicts of interest or financial interests in any product or service mentioned in the article, including grants, employment, gifts, stock holdings, or honoraria. This study was supported by an unrestricted educational grant from Purdue Pharma LP. Acknowledgments: To staff of The Dominion Group, Vienna, Va., for assistance with interviews of pharmacy school faculty and to L. Michael Posey for assistance with manuscript preparation.

References 1. Landis NT. New pain standards offer key role for pharmacy. Am J Health Syst Pharm. 2001;58:358–60. 2. Ernst ME, Doucette WR, Dedhiya SD, et al. Use of point-of-service health status assessments by community pharmacists to identify and resolve drug-related problems in patients with musculoskeletal disorders. Pharmacotherapy. 2001;21:988–97. 3. Lothian ST, Fotis MA, von Gunten CF, et al. Cancer pain management through a pharmacist-based analgesic dosing service. Am J Health Syst Pharm. 1999;56:1119–25. 4. Malone DC, Carter BL, Billups SJ, et al. Can clinical pharmacists affect SF-36 scores in veterans at high risk for medication-related problems? Med Care. 2001;39:113–22. 5. Ratka A. The role of a pharmacist in ambulatory cancer pain management. Curr Pain Headache Rep. 2002;1911–6. 6. Lipman AG, Berry JI. Pharmaceutical care of terminally ill p a t i e n t s . J Pharm Care Pain Symp Contr. 1995;3:31–56. 7. Krick SE, Lindley CM, Bennett M. Pharmacy-perceived barriers to cancer pain control: results of the North Carolina Cancer Pain Initiative Pharmacist Survey. Ann Pharmacother. 1994;28:857–62. 8. Joranson DE, Gilson AM. Pharmacists’ knowledge of and attitudes toward opioid pain medications in relation to federal and state policies. J Am Pharm Assoc. 2001;41:213–20. 9. Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree Adopted June 14, 1997. Chicago, Ill: American Council on Pharmaceutical Education; 1997. Available at: www.acpe-accredit. org/Docs/ProfProg/content_2000Standards.htm. Accessed November 13, 2002. 10. Wenzel RG, Neidich MR. Headache education in colleges of pharmacy. Ann Pharmacother. 2002;36:612–6. 11. Morrison RS, Wallenstein S, Natale DK, et al. “We don’t carry that”— failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics. N Engl J Med. 2000;342:1023–6. 12. McCaffery M, Pasero C. Pain: Clinical Manual. 2nd ed. Philadelphia, Pa: Mosby; 1999. 13. DiPiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 5th ed. New York, NY: McGraw-Hill; 2002.

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Pain management content in curricula of u.s. Schools of pharmacy.

OBJECTIVES To identify individuals in schools of pharmacy in the United States who are responsible for covering the topic of pain management in course...
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