Emily Leppien helps patients reduce pain, opioid use

Emily Leppien specialized in neurology and psychiatry during her two years of residency training, completing a longitudinal rotation at the Dent Neurologic Institute in Buffalo as well as one in a substance abuse clinic in Buffalo after earning her PharmD from the Albany College of Pharmacy and Health Sciences.

“My residence training specialized in neurology and psychiatry,” she said. “They usually fall together. What people don’t know is that psychiatric training is about 50 percent neurology and part of that neurology is pain management.”

Leppien joined the faculty at Binghamton University’s School of Pharmacy and Pharmaceutical Sciences in 2018 as a clinical assistant professor of pharmacy practice. With Lourdes Hospital implementing more clinical pharmacists in their outpatient clinics to serve patients, she now serves as a clinical neuropsychiatric pharmacy specialist at Lourdes Hospital Center for Pain & Wellness. She works as part of an interprofessional team providing pain management to patients at the clinic, seeing about 10 patients a week ranging in age from their 20s to their 80s. She also consults with members of the healthcare team as needed.

The patients referred to Leppien are those who the physician feels her intervention will benefit. And she often provides consultation on particular drugs or answers questions about supplements a patient is taking or something medication-related, such as what happens if a patient stops taking a medication.

What might surprise some is the focus Leppien and the team have to lessen the amount of opioids prescribed for chronic pain. “Yes, some patients require opioids, but we try to use integrative medicine, which includes non-medication related therapies like chiropractic, massage, acupuncture, ultra sound therapy and infrared sauna therapy. Evidence suggests that pain outcomes are better, patients have less pain and opioids are more effective if used in conjunction with these integrative therapies.”

For Leppien, the goal is to lower the doses or prescribe smaller quantities of opioids to result in better health for the patient — and a smaller amount of opioids floating around in the community.

“What has happened is that, in response to the opioid epidemic, insurance companies and some pharmacies are limiting the amount of opioids a patient can get,” she said. “It’s unfortunate because some patients really need them and when their supply is cut off they turn to illicit sources to avoid going through withdrawal.”

At the clinic, patients might also be prescribed non-opioid medications such as naltrexone, ketamine and medical cannabis to reduce the amount of opioids being prescribed.

Leppien is CDTM certified — Collaborative Drug Therapy Management certified — a designation she earned after having worked closely with physicians as a clinical pharmacist, earning board certification and completing a residency.

Not all pharmacists complete residencies, but it was important to Leppien. “I did a residency because I wanted to specialize in neuropsychology given that population of patients is highly stigmatized,” she said. “Mental illness and pain carry huge stigmas. Pain is subjective and everyone experiences it differently, but chronic pain is the leading cause of disability.”

The stigma can also come from healthcare providers who are not comfortable with opioids and see them as being harmful, she added, so when a patient is on opioids the provider automatically wonders what’s wrong with them.

“I went into this field to be able to educate providers and students in hopes of removing the stigma with these illnesses and the number-one way to do that is through education,” she said. “Students are our future healthcare providers and giving them experience working with patients with these illnesses shows them they’re no different than you or me. Understanding how to treat patients and not have a preconceived notion based on the medication a patent is picking up is important and that’s where my passion comes from.”

In neuropsychology, many of the medicines used for treatments come with a slew of side effects or drug interactions and pharmacists can play a crucial role in managing them, Leppien added. Plus, pharmacists are some of the most accessible healthcare professionals in a rural area.

“Some of our patients have pain due to a work-related or auto accident, but we also see patients with no known reason; they just have pain — maybe migraine pain, fibromyalgia pain — so there’s a huge scope in the patient population,” Leppien said.

Her CDTM certification allows her to work and collaborate with a physician and make recommendations on the physician’s behalf as a recognized provider. Leppien counsels on medication, evaluates and looks at a patient’s medication profile, and spends a lot of time eliminating medications for patients.

“I’m there to help the provider who might be seeing up to 30 patients a day,” she said. “Staying current on recommendations is one of the biggest things we can do to educate them.

“Sometimes one medication is started and doesn’t work for a patient, other times a medication is added and the first one isn’t taken away. Or, if a patient is on two medications, perhaps they can be given one that can do the same things to try to eliminate the number of medications a patient has to take,” she said. “Eliminating unnecessary medications decreases the risk of interactions or side effects.”

Another aspect of Leppien’s medication detective work is to search literature to find medications that aren’t commonly known to work for pain or a specialized illness. “For instance, ketamine is typically used to sedate a patient for surgery, but lower doses can be effective for pain management with few side effects,” she said. “Naltrexone is a very safe drug with few interactions or side effects and using it at low doses has helped with pain and allowed patients to use less opioids.”

And when asked about her role in the clinic? “It feels good,” Leppien said. “Getting a smile, even just changing one person or helping one person. Having the patient say ‘thank you’ or the student learn something. When that happens, I feel like I’ve done my job.

“If I ask a student something and they know the answer, I think, ‘YES!’”

Leppien is also conducting research on some of the non-opioid medications she works with.

“Right now I’m trying to document and look at the effect naltrexone and medical marijuana have on pain and if patients are requiring less opioids,” she said. “Is their pain being managed? Are patients with good pain control and less opioids using the integrative methods? I’m trying to improve pain and reduce opioid use and looking at how we can do that.”

Leppien hopes to quantify and publish her results so other institutions can learn from them. “It goes back to the limitations of some insurance companies or pharmacies not covering or prescribing unless there is a pain management specialist involved, and in rural areas that’s limited,” she said. “So, what can other providers recommend if a patient can’t see a pain management specialist? Other therapies do really help and not everything is just fixed with a pill. It takes work and time to go the integrative route, but it works and maybe will allow someone more time at work or more time to play with their grandchild.

“We need both medications and integrative therapies to help people live their best lives in the best manner possible.”