© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/17151635221149712
Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed for management of pain and inflammation. However, these medications are associated with adverse outcomes such as dyspepsia and acute myocardial infarction, especially with long-term uses.
Objective: We sought to determine the effect of a pharmacist-led deprescribing intervention on oral NSAID use among patients in federal custody.
Methods: Clinical pharmacists from Correctional Services Canada (CSC) conducted a prospective case series of adult patients with chronic noncancer pain who were on long-term NSAIDs (defined as >90 days supply in the past 120 days) in 3 CSC institutions in British Columbia, Canada. CSC clinical pharmacists met with patients to perform medication reviews and identify drug-related problems, with a focus on analgesic therapy. Pharmacist-led interventions were implemented in consultation with the primary care team to address these drug-related problems. Patient progress was monitored weekly for 3 months. Function, quality of life and pain severity scores (modified SPAASMS, Patient-Specific Functional Scale [PSFS] and visual analog scale [VAS] scores) were compared at baseline, 6 weeks and 3 months postintervention. Patient satisfaction survey results were also collected at 3 months.
Results: A total of 53 patients received clinical pharmacist interventions. Modified SPAASMS, PSFS and VAS scores were collected at baseline, 6 weeks and 3 months from 38 patients (some were lost to follow-up when released back into the community). All 38 patients demonstrated clinically significant improvements to all 3 pain scales at 3 months (mean SPAASMS scores decreased by 7 points, mean PSFS scores increased by 2 points, mean VAS scores decreased by 2 points). Twentyfour of 31 patients who completed the patient satisfaction survey agreed that their overall health and well-being improved because of the visit they received from the pharmacist.
Conclusion: Clinical pharmacist-led interventions in CSC have shown to reduce oral NSAID use as well as contribute positively to patient pain scores. Can Pharm J (Ott) 2023;156:85-93.
Our pharmacists and physicians were interested in assessing the impact on our patients from deprescribing systemic nonsteroidal antiinflammatory drugs (NSAIDs) and applying alternatives such as topical NSAIDs. Chronic use of oral NSAIDs is harmful. We investigated whether alternative modes of drug delivery, optimizing doses and/or instituting safer alternatives would provide adequate patient pain management.
Nos pharmaciens et nos médecins souhaitaient évaluer l’incidence sur nos patients de la déprescription des médicaments antiinflammatoires non stéroïdiens (AINS) et de la prise de médicaments de rechange, comme les AINS topiques. L’utilisation chronique d’AINS par voie orale est nocive. Nous avons cherché à savoir si d’autres voies d’administration des médicaments, l’optimisation des doses ou l’instauration d’un médicament de rechange permettraient une prise en charge adéquate de la douleur des patients.
The Correctional Service Canada (CSC) provides its patients (defined as incarcerated persons who have been sentenced by the court to serve a sentence of 2 or more years) with essential health care and reasonable access to nonessential health care that conforms to professionally accepted standards.1,2 This includes the provision of safe and cost-effective medications.
CSC pharmacists ensure the correct and safe supply of medications to their patients according to professional standards. They provide essential pharmacy services to their patients, authorize dispensing of medications based on prescription orders, provide advice on the selection of optimal costeffective drug therapy and assist in the day-to-day operations of CSC’s Regional Pharmacies. CSC pharmacists work closely with other members of CSC’s health services team to review and follow up on pharmaceutical care strategies.3
Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed to adults for the management of pain and inflammation.4 However, these medications are associated with adverse outcomes such as dyspepsia, gastrointestinal bleeding, acute myocardial infarction and acute kidney injury.5 Long-term use of NSAIDs and systemically administered formulations (e.g., oral tabs, suppositories) increases the risk of these adverse outcomes.4 The Deprescribing Initiative of NSAIDs (DIN) is a quality improvement initiative started by the Pacific Regional Pharmacy in collaboration with the CSC National Clinical Pharmacist as an extension of CSC’s Chronic Non-Cancer Pain (CNCP) Service. The CNCP service applies an interdisciplinary approach to facilitate appropriate and effective use of nonpharmacological and pharmacological pain management interventions available in CSC.
CSC clinical pharmacists are well positioned to collaborate with their patients and other members of the circle of care team as part of an interdisciplinary approach to provide evidencebased interventions to their patients who use long-term NSAIDs.
The primary objective of the initiative was to demonstrate how pharmacist-led interventions of deprescribing can reduce oral NSAID use among patients with noncancer pain in federal custody. The secondary objective was to explore the impact of the intervention on patients’ functional outcomes, chronic pain symptoms and overall pain scores.
The DIN quality improvement initiative is a prospective case series of patients seen by CSC clinical pharmacists. Patients on long-term NSAIDs were identified from 3 minimum-security federal correctional facilities in British Columbia (Kwìkwèxwelhp Healing Lodge, Mission Minimum Institution and William Head Institution). Each facility participated in the DIN initiative for 3-month periods from May 2020 to February 2021.
Patients on long-term NSAIDs were defined as those with greater than 90 days supply in the past 120 days6 and would include days prior to incarceration as needed. To participate in this initiative, patients had to be willing and able to see a clinical pharmacist.
To identify patients, active NSAID prescriptions were extracted through a search on the CSC Offender Health Information System–Electronic Medical Record (OHIS-EMR), and a master list of potential patients was created. The patients’ NSAID use was then cross-referenced to the Pacific Regional Pharmacy dispensing software system (Applied Robotics Schenectady, NY, USA) to determine use as short or long term, as described in the inclusion criteria. Once patients on long-term NSAIDs were identified, a Best Possible Medication History (BPMH) was established to include prescription medications, supplements and over-the-counter products via medication reconciliation and thorough pharmacist–patient consultation.
Consultations were scheduled to include medication reconciliation, drug–drug interaction analysis, medication review for gaps and duplication of therapy, patient education regarding self-administration and monitoring of medications, therapy optimization recommendations to health care providers and referrals to other health care professionals as needed.
For the initial visit, the clinical pharmacist conducted a thorough medication reconciliation with the patient to obtain the BPMH. The clinical pharmacist addressed medicationrelated concerns and worked with patients to develop therapeutic plans for their CNCP. A SPAASMS score7,8 (acronym defined as per bolded letters) was calculated using a composite Score on visual analog pain score, Physical activity levels, Additional pain medications, Additional sick calls/clinic visits for pain, Sleep quality, Mood, Side effects and social activity. Social activity was added as a modification to the original SPAASMS score to capture the multidimensional effects of pain on a patient. Similar to physical activity levels, this added section measured the effect of pain on social activity levels (e.g., attending cultural events, engaging in hobbies) and was weighted equally compared to the standard sections. This modified SPAASMS score ranged from 1 to 31, with lower scores being more favourable. A Patient-Specific Functional Scale (PSFS)9 was also used to measure functional outcome and quantify limitations on patient-selected activities. The PSFS score ranged from 0 to 10, with higher scores being more favourable. The visual analog scale (VAS)7,8 score was obtained as part of the SPAASMS score and used to quantify pain severity. The VAS score ranged from 0 to 10, with lower scores being more favourable. These 3 scores were measured at baseline and repeated at 6 weeks and 3 months after the initial visit.
Progress from the patient consult clinics was documented in the patient’s medical chart (OHIS-EMR). The clinical pharmacists collaborated with the primary care physicians to communicate and discuss suggestions that needed prescriber intervention. If the patient’s drug regimen did not require prescriber intervention, the clinical pharmacist would initiate drug therapy and advise other members in the patient’s circle of care team.
It was challenging to schedule in-person patient consults due to the COVID-19 pandemic and/or geographical location of the facilities. Telepharmacy was therefore used whenever possible. If in-person consults or telepharmacy were not possible, the patient’s OHIS-EMR was still assessed and pharmacist interventions were included as part of the initiative. SPAASMS, PSFS and VAS scores for patients who were monitored only by OHIS-EMR were excluded.
Follow-ups with patients occurred at 6 weeks and 3 months from the initial visit to capture changes in SPAASMS, PSFS and VAS scores. Weekly check-ups between follow-ups were also performed by reviewing the patient’s progress notes on OHIS-EMR and consulting with the nurses. This provided continuous monitoring of the patient’s progress. Patient surveys were collected to provide information on patient satisfaction regarding their experience with the DIN quality improvement initiative.
At the end of the initiative, a snapshot of the number of patients seen, number of pharmacist recommendations made, physician acceptance rate and reasons for nonacceptance was calculated. The pharmacist recommendations were categorized to appreciate the type of medication optimization made.
For the primary analysis, the proportion of patients with reduced oral NSAID use was calculated. For secondary analyses, mean differences and 95% confidence intervals were calculated between each time point to use all available data and analyzed using Excel (Microsoft, Redmond, WA, USA) using standard formulas for statistical inference as outlined by D’Agostino et al.10 Confidence intervals with a 95% confidence interval are equivalent to a null-hypothesis test (e.g., analysis of variance and chi-square), where the result is statistically significant at an alpha level of 0.05 if the null hypothesis (i.e., 0, or no effect, unless otherwise specified) does not fall within the 95% confidence interval. P values are also provided using paired samples t tests for continuous data.
Of the 103 patients identified as potential candidates for the initiative, 50 patients were excluded (45 declined to see the pharmacist, 2 were on work release and 3 were released back to the community). As a result, a total of 53 male patients received clinical pharmacist interventions (Figure 1). Overall, there were a total of 36 in-person consults, 7 telehealth consults and 10 OHIS-EMR assessments.
The mean (SD) age of patients included was 53 (11) years. The mean (SD) number of medications each patient took was 6.6 (4.5). The mean (SD) number of pain diagnoses per patient was 2.4 (2.2). As the process for categorization of specific pain diagnoses was not yet standardized within the OHIS-EMR, pain diagnoses were instead categorized by location (Table 1) via information from various sections of the EMR or in discussion with the clinical team and/or patient. Concomitant medical conditions are described in Table 2. The causative factor for CNCP was not recorded for the most part. However, through discussion with patients, pharmacological and nonpharmacological options were discussed based on their history, chief complaint and their acceptance of the recommendations of the clinical pharmacists.
Prescribed analgesics at baseline and at 3 months after clinical pharmacist interventions for the 3 facilities are presented in Table 3. These numbers include patients who were released prior to the end of the initiative. Analgesic regimens include both regularly scheduled regimens and as-needed regimens.
At the start of the initiative, 37 of the 53 patients (70%) were on oral NSAIDs (Table 3). Twelve of these 37 patients had their medication deprescribed at 3 months (32.4%; 95% confidence interval [CI], 17.3%, 47.5%). As a result, 25 of the 53 patients (47%) were on oral NSAIDs at 3 months. The percentage of patients on topical NSAIDs remained unchanged from baseline to 3 months (43%). Among these patients, the most common topical NSAID was diclofenac 10% gel at baseline. The most common topical NSAID became diclofenac 2.32% gel at 3 months.
Thirty-eight patients had SPAASMS, PSFS and VAS scores at all 3 time points; a further 5 had scores at 6 weeks only, as they were released before the 3-month follow-up. Given the small numbers, we did not examine whether improved outcomes were related to release from the correctional facilities, as we would have had extremely limited statistical power and potentially introduced privacy risks of reidentifying individual patients.
Statistically significant improvements were observed on all 3 pain scales at the 6-week follow-up, with further improvements between 6 weeks and 3 months (Table 4). SPAASMS scores decreased by almost 7 points in total, with a roughly 3-point decrease at 6 weeks and nearly 4 points at 3 months. PSFS scores increased by approximately 2 points at the 3-month follow-up, with most of this change between the 6-week and 3-month follow-up. The VAS scores decreased by nearly 2 points at the 3-month follow-up, with roughly 1-point decreases between each follow-up.
The clinical pharmacists documented 153 drug-related problems, with subsequent interventions for pain management, for a total of 51 patients (mean of 3 drug-related problems with subsequent interventions per patient). Interventions included medication initiations, referral to primary care provider for medication initiations, medication adjustments, medication discontinuations, adherence interventions and nondrug interventions (Table 5). The clinical pharmacists worked within the scope of their practices in implementing medication changes. Each patient’s respective primary care physician accepted all pharmacist interventions.
A total of 31 patients completed patient satisfaction surveys, which had 5 statements. Table 6 describes the number and proportion of these patients who answered “agree†or “strongly agree†to these statements. A majority of these patients (24 out of 31) agreed that their overall health and well-being improved because of the visit they received from the pharmacist. There were no patients who answered “disagree†or “strongly disagree.â€
The DIN quality improvement initiative demonstrates that a proactive approach in CNCP management, with the patient at the centre, can potentially improve patient quality of life. The optimization of medications for the management of CNCP, including the process of deprescribing, positively affects all dimensions of patients’ lives, including sleep quality, mood, physical activity and social interactions, as demonstrated by the decrease in mean SPAASMS score from 16.01 to 9.18, increase in mean PSFS score from 5.97 to 7.91 and decrease in mean VAS score from 5.26 to 3.36 at 3 months.
The initiative resulted in a decrease in percentage of patients on oral NSAIDs from 70% at baseline to 47% at 3 months postintervention. This finding is congruent with other research that found a decrease in the rate of NSAID use and inappropriate NSAID prescribing after pharmacist intervention.11,12 While discontinuation rates of oral NSAIDs were notable in our cohort, the number of patients on topical NSAIDs remained the same (23 patients). However, deprescribing of NSAIDs was still successful in this category, as all patients who were originally on diclofenac gel 10% eventually reduced their dose to diclofenac gel 2.32%. At 3 months, only 1 patient remained on diclofenac gel 10%, but only after an adequate trial of the lower-strength diclofenac gel. Patients not initially on acetaminophen benefitted from safer alternatives to pain medications, as demonstrated by the increase in the number of patients on acetaminophen at 3 months. Patients who were originally on acetaminophen also benefitted through dose optimization based on the drug’s half-life (e.g., dosing every 4-6 hours instead of every 12 hours). The pharmacist consultations provided an opportunity for a detailed assessment of the patient’s type of pain and previously tried therapies. In collaboration with the physician, this allowed patients to receive more individualized treatment, and this is shown by the increase in the variety of medications at 3 months (e.g., sumatriptan, lidocaine 2%). Four patients underwent successful discontinuation of all analgesics, supporting the pharmacist’s role in reducing unnecessary medication use.
The clinical pharmacist performed an average of 3 interventions per patient, with the most common types of intervention being medication adjustments, adherence interventions and nondrug interventions (Table 5). This demonstrates not only the need for clinical pharmacists in a segment of the correctional population but also the broad scope of pharmacy practice in providing medication expertise as well as healthy lifestyle advice. Deprescribing of medications other than NSAIDs was also observed. Observations showed that when CNCP is managed effectively, patients sleep better and therefore medications used for sleep can also be discontinued or tapered to the lowest effective dose; however, this was not objectively measured. In addition, rational discontinuation of NSAIDs helped some patients taper or discontinue proton pump inhibitors or switch to histamine-2 antagonists, in those who used them, to decrease the gastrointestinal effects of NSAIDs; however, this was not objectively measured. The physician acceptance rate for pharmacist interventions was 100%, illustrating the positive perception physicians have of the role of clinical pharmacists within the health care team. High rates of physician acceptance were also evident in another study involving pharmacist-led NSAID deprescribing interventions.13 In addition, based on the survey results (Table 6), patients expressed their gratitude and satisfaction with accepted interventions and showed improvement in their overall well-being.
One of the limitations of the initiative was the lack of a control group as a comparator. As pain can fluctuate and be influenced by placebo effects, the presence of a control group would help to confirm that the positive outcomes can be attributed specifically to pharmacist interventions.
The participants were 100% male, which reflects the patient population at the 3 sites. However, this does not reflect the patient population in other non-CSC settings such as hospitals, long-term care facilities or the community. A number of patients also refused to meet with the pharmacist. While this may pose as a barrier to generalize the results, this initiative still demonstrates that pharmacist-led initiatives can be successfully implemented and valued, even in unique settings such as a correctional facility.
Many patients were offered telepharmacy, as in-person visits had been temporarily stopped during the ongoing COVID-19 pandemic. Although seeing patients virtually provides an avenue to continue the provision of pharmaceutical care in this context, it may have had a negative impact on the number of patients enrolled in this initiative. For instance, patients who prefer in-person consults may decline to see the pharmacist if only given the option of virtual consults. Additionally, not all the sites had the proper equipment or staff resources to facilitate telepharmacy services. The high refusal rate at William Head Institution may be attributed to the lack of staff to facilitate telepharmacy as well as difficulty in engaging patients at a distance (William Head Institution is the farthest facility from the pharmacy). This quality improvement initiative does offer reassurance that it is possible for clinical pharmacists to work to their full scope of practice remotely through telecommunications technologies during the pandemic. However, in-person visits facilitated more trust and collaboration with the patients and the health care team.
Another limitation of the initiative was the proportion of patients who did not fill out the satisfaction surveys. This was largely due to the fact that the forms were not received by patients who only obtained OHIS-EMR assessments. Operational and security concerns also made it difficult to hand out and retrieve surveys at the sites. While it is possible that those individuals who did not fill out the forms may have been less satisfied with the changes made, at least the completed surveys demonstrated that most patients were grateful for the consult services, saw the value in their discussions regarding medication optimization with the clinical pharmacists and asked that such services be continued.
Further research is required to explore how pharmacist-led NSAID deprescribing initiatives in correctional settings affect other clinical outcomes such as reduction in hospital admissions. Performing this quality improvement initiative in other federal correctional facilities across the country would also provide information on how varied scopes of practices in different provinces affect clinical outcomes. In addition, more research is needed to explore the differences that in-person visits and telehealth encounters may have on factors such as patient enrolment, clinical outcomes and patient satisfaction.
The DIN quality improvement initiative resulted in reduced oral NSAID use as well as improvement in pain scores among patients in federal custody in the context of chronic noncancer pain. Working in collaboration with the health care team, clinical pharmacists have a valuable role in optimizing medications and pain outcomes.
From Mission Institution (Dawson), Mission, British Columbia; Correctional Service Canada, National Headquarters (Bhalla), Ottawa, Ontario; Pacific Regional Hospital Pharmacy (Wong, Mok), Abbotsford, British Columbia. Contact vanessa.mok@csc-scc.gc.ca.
Author Contributions: All authors critically reviewed the manuscript and approved the final version of the article. Each author participated in the patient consultations by meeting with the patients, reviewing the pharmacists’ recommendations or tabulating the results of the initiative. The authors acknowledge the contributions of Dr. Michael Martin and appreciate his expertise with the statistical analysis of the article.
Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding: The authors received no financial support for the research, authorship and/or publication of this article.
ORCID iD: Vanessa Mok https://orcid.org/0000-0001-8793-7020
