Everybody experiences pain at some point in their life and community pharmacy is often the place people turn to for advice and support, says Asha Fowells

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Key learning points

• Pain is complicated, involving several processes in the body, which in turn can make it difficult to manage.

• Analgesics are often the mainstay of pain management, but adjuvants have an important role in treatment, as do self-help measures.

• Pharmacists and their teams have a crucial role in advising and supporting patients with pain, from recommending OTC products to providing information on organisations, groups, courses and therapies that may help, and signposting other resources that may be helpful.

Pain is unpleasant, but a given in life. After all, it is the body’s way of alerting us to the fact that something has gone awry, whether that is the result of an infection, a disc that has slipped out of its usual place in the spine, or a million other reasons. In many cases, the discomfort is mercifully short-lived and resolves relatively easily.

But, in other cases, the pain persists for weeks, months or even years, which can have a profound effect on the life of the sufferer and often their close family and friends.

This article goes back to basics, looking at what causes pain and how it is categorised and managed so that pharmacists and their teams are equipped to provide appropriate advice and support to patients.

Understanding and categorising pain

In order to understand how pain is categorised – and managed in terms of how the various drug classes used for analgesia exert their action – it is necessary to grasp what causes pain in the first place.

When an area of the body is damaged, sensory receptors called nociceptors send signals via the spinal cord to the brain, which then uses neurotransmitters to communicate back to the affected site: this is felt as pain. Reducing the transmission of nociceptive impulses decreases the brain’s perception of pain and is how opioids bring to bear their analgesic effect.

An individual’s emotional state influences the quantities of neurotransmitters present in the body, which are necessary to communicate from the brain to the part of the body that is out of kilter.

Someone who is depressed, for example, has lower levels of noradrenaline and serotonin, which normally help block the pain signal, so higher discomfort levels are experienced. This is the reason that antidepressants are sometimes used in pain management.

At the same time that nociceptors start firing, tissues near the affected site start releasing prostaglandins, which amplify the pain signal and force the sufferer to restrict themselves from doing anything that could exacerbate the problem. Blocking this prostaglandin release reduces pain and is the rationale behind analgesics such as paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs).[1,2,3] 

The location of the nociceptors that inform the brain of a problem dictates how pain is experienced:

• Somatic pain originates in the skin, bone, muscles and joints, usually feels sharp and localised, and is aggravated by moving the injured part.

• Visceral, or soft tissue pain, arises in the thorax, abdomen and pelvis, is often described as achy or cramping because it is unlocalised, but tends to be continuous.

• Neuropathic pain starts in the central nervous system and is often felt as a shooting or burning pain. Because it stems from nerve damage, the pain signals often continue to fire after the immediate cause has been removed.

• Referred pain is felt in a different part of the body to where the problem originates from; for example, a liver issue can cause pain in the shoulder because of compression of the phrenic nerve.

• Phantom pain affects a part of the body that has been removed, for instance leg pain after an amputation. The pathway for this is not well understood, which makes it difficult to treat.[4,5]

Pain is further categorised by how long it lasts.

According to the British Pain Society, there are three classifications for pain:

• Acute or short-term pain usually has a sudden onset and a clearly identifiable cause, such as sustaining a burn while cooking, and lasts no longer than a few days.

While unpleasant, it often serves a useful purpose in triggering reparative action, eg taking a baking tray out of the oven with bare hands causes pain that results in the individual dropping the tray, thereby minimising further damage. Addressing the cause usually resolves the problem, eg taking heat out of the burned area by applying a towel soaked in cold water.

• Recurrent or intermittent pain is acute pain that comes and goes, for example, toothache. Again, addressing the issue usually eases the pain, though the exact cause may be difficult to pinpoint and some conditions – period pain, for instance – require regular management, though usually not for long on each occurrence.

• Chronic pain differs from recurrent pain in that it is unrelenting, though there will be times when it feels more severe than others, and it lasts three months or longer. The cause is usually a long-term condition such as arthritis, though it may be less specific, for example a painful back.

Chronic pain can have a huge effect on quality of life, causing problems with mobility, dexterity, sleep and concentration. It often results in the sufferer changing how they live in order to cope. This, in turn, can have a huge bearing on emotional wellbeing, causing anxiety, helplessness and depression.[6]

Assessing and managing pain

If a patient complains of pain, asking a number of questions can help inform the advice – and product recommendations, if appropriate, can be provided:

• Where does it hurt? Is it very specific, several areas of the body, or all over?

• How long has it been going on?

• How would you describe it?

• How bad is it on a scale of zero to 10, where 10 is the worst pain you have ever experienced?

• When does it happen and is it constant or intermittent? This question also helps evaluate whether the patient is being kept awake or woken by the pain during the night.

• Does anything make it better or worse, for example sitting or lying down or any pain relief measures?

• How is it affecting your life? Does it stop you doing something you would usually do without thinking, such as moving around, eating or concentrating at work?[7]

Being asked so many questions can be overwhelming, particularly for individuals who are experiencing chronic pain, which often changes day to day, hour to hour, or even minute to minute. A pain diary can be very helpful in such circumstances.[8]

In terms of management, a good approach is the 'analgesic ladder' advocated by the World Health Organization. Originally developed to help improve the management of cancer pain, the stepwise tactic is equally applicable to many painful conditions:

•Step 1 (mild pain): non-opioid, eg aspirin, paracetamol or an NSAID, with an adjuvant if appropriate. If the pain persists or worsens, move to step 2.

•Step 2 (mild to moderate pain): weak opioid, eg codeine, with or without a non-opioid and/or adjuvant. If the pain improves markedly and the cause is resolving, drop back to step 1. If it persists or worsens, move to step 3.

•Step 3 (moderate to severe pain): strong opioid, eg morphine, with or without a non-opioid and/or adjuvant. If the pain improves markedly and the cause is resolving, drop back to step 2.

An adjuvant is a medicine usually used for a non-painful condition that has analgesic properties in certain situations. Examples include antidepressants, corticosteroids, neuroleptics, bisphosphonates and muscle relaxants.[9]

The oral route is preferred at all stages of the pain ladder, but other routes may be preferable in certain situations. For example, a cancer patient with breakthrough pain needing quick relief may benefit from a sublingual preparation, and a patch is likely to be a better option for someone with swallowing difficulties. If pain is chronic and continuous, analgesics should be given regularly rather than on a ‘when required’ basis.

This is something that can be difficult for patients to follow, having heard the messages over the years that painkillers should only be used when needed. Therefore, pharmacists and their teams have a role to play in explaining that keeping pain under control is easier than trying to tackle it when it flares up.[10]

Because of the huge range of conditions and factors that can cause and influence pain, many individuals find that they do not fit neatly into one medical discipline, which can mean delays to diagnosis and treatment. Furthermore, funding cuts to the NHS are negatively impacting specialisms - such as pain services - and the difficulties many patients experience in getting GP appointments are well documented.

All this means that the support that pharmacists can provide to this patient group is more valuable than ever - and needs to extend beyond the usual advice and counselling on both OTC and prescribed medicines.[11]

A report published jointly by the UK Clinical Pharmacy Association (UKCPA) and University College London (UCL) School of Pharmacy suggested a number of ways in which community pharmacy could help prevent long-term pain or significantly improve its management, including delivering self-care support to raise awareness of the types of pain that need prompt relief and those that need accepting and working through.

The Royal College of Anaesthetists Faculty of Pain Medicine further built on this publication, highlighting the place of services such as Medicine Use Reviews (MURs) in monitoring the effectiveness and tolerability of opioids, and describing a number of other possible interventions pharmacists could make, including collaborating with local GP surgeries to provide better pain management, and, in the case of independent pharmacist prescribers, running regular pain clinics and, in some cases, assuming a direct case management role.[12, 13]

Pharmacists can also help patients in pain by signposting patient organisations – these are usually disease specific, for example, Arthritis UK and Diabetes UK, though others such as Action On Pain and the British Pain Society are more general – and pain services, such as clinics and self-management programmes.

It is sensible to encourage patients to adopt a holistic approach to how they manage chronic pain by including gentle exercise, pacing and relaxation techniques in their day-to-day lives, doing everything they can to get a good night’s sleep, and making sure they do not become socially isolated.

The painful truth

• According to the British Pain Society, up to 28m people in the UK are living with chronic pain.[1]

• Many days at work are lost due to pain-related problems: 4.9m days to work-related back pain, according to the TUC, and 9.4m days as a result of rheumatoid arthritis, as estimated by the National Rheumatoid Arthritis Society, for example.[1]

• The cost of chronic pain is unknown, but for back pain it has been estimated to be in the region of £5bn per year to the Exchequer, and studies put a figure of nearly £4bn per annum on how much the NHS spends on adolescent pain per year.[1]

• Pain relief is the biggest over-the-counter (OTC) category, worth £576.9m in the 12 months to April 2016, up nearly 2% from the previous year.[2]

• Analgesic prescribing is also on the rise. According to figures published by NHS Digital, nearly 69m prescriptions were dispensed during 2015 for opioid and non-opioid analgesics, such as paracetamol and Aspirin, at a cost of £567.4m. This represented an increase of 200,000 items and £32m on the previous year and also a rise of over 21m prescriptions and £230m across the decade.[3]

• In 2015, 24.4mi prescriptions were dispensed in the community for rheumatic disease and gout drugs - a category that includes NSAIDs, costing over £160m.

Asha Fowells is a freelance journalist and community pharmacist.

References

1 http://www.brainfacts.org/Sensing-Thinking-Behaving/Senses-and-Perception/Articles/2012/Touch-and-Pain

2 http://www.news-medical.net/health/Mechanism-of-Pain.aspx

3

4 http://www.medscape.com/viewarticle/409025_3

5 http://www.cancerresearchuk.org/cancer-help/coping-with-cancer/coping-physically/pain/types-and-causes-of-cancer-pain

6 https://www.britishpainsociety.org/about/what-is-pain/

7 https://cks.nice.org.uk/palliative-cancer-care-pain#!scenario:1

8 http://www.nhs.uk/ipgmedia/National/Macmillan%20Cancer%20Support/assets/UsingacancerpaindiaryMCS4pages.pdf

9 http://theoncologist.alphamedpress.org/content/9/5/571.full

10 https://www.ncbi.nlm.nih.gov/books/NBK554435/

11 http://www.action-on-pain.co.uk/you-and-chronic-pain/about-chronic-pain/

12 https://www.ucl.ac.uk/news/news-articles/January2012/10012012-nhs-users-suffering-preventable-pain

13

14 http://www.nhs.uk/Livewell/Pain/Pages/10painself-helptips.aspx

15 http://www.nhs.uk/Livewell/Pain/Pages/Longtermpain.aspx

16 http://www.nhs.uk/Livewell/Pain/Pages/Gettingphysical.aspx

Resources

• The British National Formulary provides a useful overview of analgesic drugs here.

•For patients, simple to understand information on painkillers can be found on the NHS Choices website here.

•Macmillan Cancer Support’s website has a section entitled “Common questions about painkillers” that addresses questions about the risk of addiction and so on that patients on regular analgesia may find helpful here.

•Macmillan also has a pain diary that can be downloaded, along with information on how to use it, here.

•Catch My Pain is a pain diary app that can help patients keep track of their pain as well as connect with other sufferers. It can be accessed here.

•WHO’s analgesic ladder can be viewed here.

•A toolkit designed to help patients with chronic pain better understand and cope is downloadable here.

•Information on self-management courses is accessible here.