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Christ et al
administration, vital signs, pain assessment information, and
laboratory data. The PCDST was designed to aid the pharmacist in identifying patients who require assessment and display
patient-specific information to assist clinical decision making.
Pharmacists have been shown to improve pain outcomes
in both cancer and noncancer patients in both the inpatient
and outpatient settings.9-11 Furthermore, clinical decision
support tools (CDSTs) have demonstrated improvement in
guideline adherence, pain relief, and safety, but studies supporting CDSTs have generally been methodologically weak
with no focus on the impact of pharmacist-managed
CDSTs.12-15 Therefore, we set out to assess the impact of a
pharmacist-managed PCDST on opioid-tolerant inpatient
oncology patients at risk for uncontrolled pain.

Table 1. Long-Acting Opioids for Screening in Drug Utilization
Review.

Methods

Note. SR = sustained release; CR = controlled release.

This study was a single-center, retrospective, cohort study,
conducted at the University of Chicago Medicine and
approved by the Biological Sciences Division Institutional
Review Board. This research received no specific grant from
any funding agency in the public, commercial, or not-forprofit sectors. All adult patients admitted to the inpatient
hematology/oncology service who received at least 1 dose of
long-acting opioid were included in the analysis. Patient
selection included patients with solid tumors and hematologic
malignancies and/or history of stem cell transplant. A historical cohort of patients from 2011 was used from a previous
study at our institution.8 The postimplementation group was
evaluated between November 1, 2013, and January 15, 2014.
Patients were excluded if any of the following applied: initial
pain score was less than 4, length of stay was less than 24
hours, patient-controlled analgesia (PCA) or continuous infusion opioids were used, initial admission was to a nononcology service, or if there was incomplete information.

Data Collection
Baseline characteristics including age, sex, presence of metastatic disease, opioid allergy, serum creatinine, alanine aminotransferase (ALT), aspartate transaminase (AST), and total
bilirubin were recorded. Renal dysfunction was defined as a
calculated creatinine clearance less than 50 mL/min, and
hepatic dysfunction was defined as total bilirubin, AST, or
ALT greater than 3 times the upper limit of normal. Pain
scores were recorded from admission through hour 28, as
this was the time point data collected in the published preimplementation data.8 Opioid medications prior to admission
were obtained as recorded in the electronic medical record to
assess for opioid tolerance. Pharmacist intervention was
measured through i-Vents, an electronic tool to document
specified interventions, in the EPIC EMR. Safety data
including respiratory rate, oxygen saturation, and naloxone
use were recorded.

Opioid
Fentanyl
Fentanyl
Fentanyl
Fentanyl
Methadone
Methadone
Methadone
Morphine
Oxycodone
Oxycodone
Oxycodone

Strength

Dosage form

12 mcg/h
25 mcg/h
50 mcg/h
100 mcg/h
5 mg
10 mg
10 mg/mL
15 mg
10 mg
20 mg
40 mg

Transdermal patch
Transdermal patch
Transdermal patch
Transdermal patch
Tablet
Tablet
Oral liquid
SR tablet
SR tablet
CR tablet
CR tablet

Definitions and Endpoints
Opioid tolerance was defined as the patient receiving at
least 60-mg oral morphine/day or equivalent, including
25-mcg transdermal fentanyl/hour, 30-mg oral oxycodone/
day, 8-mg oral hydromorphone/day, 25-mg oral oxymorphone/day, or an equianalgesic dose of another opioid for 1
week or longer. Identification of inpatient long-acting opioid use was used by an electronic drug utilization review
(Table 1). Note that due to hospital formulary, multiple oral
or transdermal dosage forms are combined to obtain the
prescribed dose. Attainment of analgesia was defined as a
pain score ≤4 or a 50% reduction in pain from baseline
(baseline pain scores of 9 required a pain score of 4 in order
for analgesia to be considered attained). A pain score of 4
was used based on institutional policy recommending more
frequent pain assessment in patients reporting a pain score
of 4 or greater. Adherence to NCCN guidelines for opioidtolerant patients was defined as patients receiving 10% to
20% oral morphine equivalent of short-acting opioid with
respect to their total daily dose. The primary endpoint was
attainment of analgesia at 24 hours from admission.
Secondary endpoints included time to analgesia (in patients
achieving analgesia in ≤28 hours), mean pain score, number of pain score nursing assessments in the first 24 hours,
frequency of pharmacy intervention, and percent of patients
with NCCN guideline-adherent pain regimens. Safety endpoints included opioid-induced adverse events including
respiratory rate less than 10 breaths per minute, oxygen
saturation less than 90%, and naloxone use.

Pharmacist Training
All clinical pharmacists, including pharmacy residents,
received training on use of the PCDST prior to the implementation in November 2013. The hematology/oncology
clinical specialists had access to the tool prior to expanding

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