___________________ Opioid Stewardship in Multimorbidity: Balancing Pain, Function, and Polypharmacy
THE CLINICAL PHARMACIST’S ROLE Clinical pharmacists uniquely positioned to optimize medica- tion regimens in multimorbid patients can: • Conduct comprehensive medication reviews, identifying all potential drug-drug interactions, not just opioid-related ones • Recommend dose adjustments based on renal and hepatic function, preventing accumulation toxicity • Suggest therapeutic alternatives when interaction risks are excessive • Coordinate deprescribing strategies, safely discontinuing medications no longer necessary • Provide patient education about proper medication use, storage, and disposal Studies demonstrate that pharmacist-involved pain manage- ment services reduce opioid doses, improve pain control, and decrease adverse events [27]. For multimorbid patients, pharmacist collaboration is essential, not optional. Structured medication therapy management programs, increasingly com- mon in integrated health systems, provide frameworks for this collaboration [28]. BEHAVIORAL HEALTH INTEGRATION Chronic pain is inseparable from psychological well-being. Depression, anxiety, and post-traumatic stress disorder (PTSD) amplify pain perception while increasing opioid misuse risk [29]. Conversely, uncontrolled pain exacerbates psychiatric conditions, creating bidirectional causation that medication alone cannot address. Integrated behavioral health models that embed psychologists, social workers, or psychiatric nurse practitioners in primary care enable: • Screening and treatment of comorbid mental health conditions • Cognitive-behavioral therapy for chronic pain, addressing maladaptive pain beliefs • Motivational interviewing for patients resistant to tapering or non-opioid alternatives • Substance use disorder assessment and treatment when opioid misuse emerges • Sleep hygiene counseling, as insomnia worsens both pain and mental health
The biopsychosocial model of pain posits that biological, psychological, and social factors interactively determine pain experience [30]. Multimorbid patients exemplify this complexity; their pain influenced by inflammatory arthritis (biological), depression (psychological), and social isolation (social). Addressing all three domains requires interprofes- sional coordination extending beyond traditional medical care.
CASE APPLICATION: BRINGING CONCEPTS TOGETHER
Consider Patient M, a 72-year-old woman with type 2 dia- betes, chronic kidney disease (stage 3b), hypertension, heart failure, depression, and osteoarthritis. Her current medica- tions include metformin, lisinopril, carvedilol, furosemide, sertraline, and as-needed tramadol for knee pain. She reports her pain level is 6/10, limiting her ability to grocery shop independently. Patient M faces multiple interaction risks—tramadol with ser- traline (serotonin syndrome), tramadol with renal impairment (accumulation), polypharmacy burden (nine medications), and functional limitations. Her depression increases opioid misuse risk, while her age and renal disease heighten adverse effect susceptibility. The patient’s healthcare team creates a collaborative care plan that includes: • Pharmacist consultation: Reviews medication list, identifies tramadol-sertraline interaction, notes inadequate renal dose adjustment for several medications, recommends alternatives • Tramadol discontinuation: Switch to scheduled acetaminophen 650 mg three times per day and topical diclofenac gel to knee twice per day • Physical therapy referral: Focus on quadriceps strengthening and gait training to improve grocery shopping capacity (functional goal) • Optimize depression treatment: Ensure sertraline is at therapeutic dose; consider referral to embedded behavioral health clinician • Follow-up plan: Reassess pain and function in two weeks; if inadequate, consider duloxetine (addresses both pain and depression), with pharmacist involved in sertraline-to-duloxetine transition to prevent serotonin syndrome
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