The myeloma team at Beatson Cancer Centre have successfully integrated a specialised pain service within their myeloma outpatient clinic. Paul Gallagher, a senior pharmacist with expertise in cancer pain, offers pain management consultations to patients when they attend the hospital for clinic appointments.
Here, Paul sheds light on the unique pain service he provides, highlighting the remarkable benefits this service brings to myeloma patients. Plus, he shares valuable insights gained during the service’s first year of operation.
What prompted this initiative?
In recent years, the number of patients attending the myeloma outpatient clinic has increased two to three-fold. The increased number of treatment options available, including maintenance treatment, means that patients stay on treatment for longer, subsequently living longer as survival rates improve. Like many other centres, the capacity of our clinic to cope with this increase in demand was stretched.
With more patients to assess for treatment toxicities, our team’s doctors and clinical nurse specialists (CNSs) find they have less dedicated time to spend with each patient. Alongside this, several of the newer treatment options for myeloma have neuropathic pain as a side effect. This has resulted in an increased number of patients attending the clinic with complex pain needs that require ongoing management.
At the same time, within our Health Board, there has been a drive towards pharmacists broadening their clinical role. As an independent prescriber, I saw an opportunity to use my qualification within the myeloma service. Having stepped away from oncology into palliative care, it made sense to use my skills within a clinic where my knowledge of analgesics and patient support could be applied within a pain specialist role.
What were the potential benefits for patients?
Integrating a specialist pain management service in the myeloma clinic would help patients by providing:
- Ease of access to a specialist familiar with the complex toxicity profile of myeloma treatments, providing dedicated consultation time to discuss and manage pain symptoms effectively
- Improved continuity of care for ongoing pain management from a specialist embedded in the myeloma team. This can reduce patients’ reliance on their GP, who may be less familiar with myeloma treatment combinations
- Reduced cost and travel burdens for the patient by combining their chemotherapy assessment and pain management consultation into one visit. Joint assessments with different members of the healthcare team can also promotes coordinated care
- Prompt initiation of analgesia, as medications can be prescribed during consultations and dispensed from the hospital pharmacy the same or the next day
- Ample time for thorough counselling on prescribed analgesics, allowing patients to fully understand their treatments and address any questions or concerns they may have
Patients can also regain consultation time with the doctor or CNS to discuss other aspects of their myeloma diagnosis and treatment.
How does the clinic operate?
Initially, patients could only access the service during their scheduled myeloma appointments. In the myeloma clinic, the doctor or CNS assess the patient as part of their regular review. If they feel a pain consultation would be helpful, they direct the patient to my room for review. Patients can also be referred to me in advance of the clinic. It is important that the specialist pain pharmacist has a dedicated room within the clinic so that they are on-site and available for consultations at the appropriate time.
After the consultation, I write a summary in the patient’s electronic record for easy access by other team members.
To maintain a clear and consistent approach to pain management, I do not see patients who are under the care of the community palliative care or pain management team for their pain management.
Reflecting on the first year
Approximately 40 patients have been reviewed in the clinic we established the service. About 90% of these patients were reviewed regularly (10% were seen only once). Of these 40 patients, 32 were on active treatment for their myeloma.
My prescribing has covered commencement, titration and cessation of opioids. Depending on the patient’s needs, I can also prescribe several adjuvant analgesics such as gabapentinoids or lidocaine plasters
Continuous learning and development are vital to ensuring the service meets the needs of patients and enhances their overall care. As the service has become more established, we have already made some changes, including:
- Addressing patients’ concerns about painkiller addiction: I updated the patient information leaflet for patients starting opioids. It now includes a paragraph to alleviate the fear of addiction.
- Reviewing patients only at their myeloma appointment is not always practical: For example, if the patient needs rapid dose titration or a change of analgesia, it’s not suitable for them to wait four weeks to see me. I now offer phone consultations or can see patients when they attend the hospital for their chemotherapy treatment when needed.
- Keeping up to date on myeloma and its treatment: My background is in palliative care and oncology; getting up to speed with myeloma was an initial challenge. However, the myeloma team at the Beatson have been very welcoming and always available to assist me when I need them.
Future developments
There are no cross-cover arrangements in place for my clinic as there is currently no-one able to cover me when I am on leave. This is something that needs to be examined as the service grows.
Feedback from patients has been positive, but I am currently exploring ways of formally evaluating patients’ experience of the pain clinic. The findings would contribute to the overall evaluation and development of the service and the sharing of its outcomes with fellow pharmacists and health professionals at conferences and meetings.
Paul Gallagher
Palliative Care/ICPS Pharmacist
Beatson West of Scotland Cancer Centre