Community pharmacists are well placed to offer patients a service to help manage their pain, writes Mark Robinson
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Key learning points
•28 million adults in the UK suffer from chronic pain
•Many patients feel their pain is not adequately contolled
•Addiction to prescribed medicines may be a growing problem
Community pharmacy has unequalled access to people with chronic pain through the dispensing of medicines and sale of over-the-counter (OTC) products. Chronic pain can have a devastating impact on people’s lives and many would benefit from better treatment strategies focusing on living with pain.
Community pharmacy is perfectly positioned to help people with chronic pain through assessment and the co-development of an action plan with realistic goals. The pharmacy can offer alternatives to simple analgesics, including referrals to other service providers. We may not always be able to cure the pain, but we can help people live a more active and productive life.
Community pharmacy has an existing role in the management of pain. This is evident through the volume of prescriptions dispensed and the wide range of simple analgesics offered.
Between one-third and a half of all adults in the UK suffer from chronic pain, corresponding to about 28 million people.
Pain is very individual and only the person feeling the pain can properly describe it. Some pains are obviously a simple response to an injury and after the injury is healed, the pain goes. Many chronic pains can be less obvious and they can affect every part of a person’s life.
Chronic pain can affect their ability to work, their relationships with family and friends, activity levels, sleep and independence. All of this can become overwhelming and can cause a vicious circle of pain and distress.
It is now widely accepted that longstanding pain and disability can only be understood and managed within a biopsychosocial model. Since people’s beliefs about pain, disease and disability are the largest predictors of pain-associated disability, treatment must address the role of biological, psychological and social factors as obstacles to recovery.
We also know that there is a growing problem of addiction to prescribed medicines. A recent report in New Scientist described addiction to prescribed drugs as a public health disaster. The authors clarify that for short-term and cancer pain opiates might be the best, but in the long term the drugs become ineffective and can sensitise pain nerves, meaning that over time non-painful stimuli become painful.
The proposed change
Community pharmacy can create an improved pain management service by structuring the way we identify and engage with people who have chronic pain.
There are some important questions to ask:
• Which patients will I look at?
• How will I assess my patients?
• How will I set goals?
• What treatments could I offer?
Which patients will I look at?
Patients who have chronic pain – defined as a pain lasting more than three months – are in need of an enhanced solution. The simplest way to identify them is to ask them, but they can also be identified through their patient medication record when you see that analgesia has been repeated over the past three months.
Patients can be engaged through a brief conversation in the pharmacy, but they will usually need some time for assessment and to explore appropriate solutions. They could be invited to a medicines use review (MUR), particularly if they say their current treatment is inadequate.
Offering a leaflet that describes the service offered and encouraging the patient to book an appointment might be useful.
Pharmacists should also know when to refer. Obviously, if after assessment, you feel that there might be a serious unknown pathology behind the pain, you should urge the patient immediately to seek an expert opinion. Also consider this if the patient:
• Has moderate to high levels of distress.
• Has difficulty adjusting to a life with pain.
• Is struggling to change their behaviour to maintain normal activities.
• May require additional treatment not available within the pharmacy.
How will I assess my patients?
The most important element of the pain service is the assessment. There are several simple questionnaires to deliver this, but you must consider the following:
• Biomedical assessment
A thorough pain history assessing each pain experienced:
– Site, character, intensity, onset, precipitants, duration, exacerbating and relieving factors, night pain, perceived cause.
– Systemic symptoms, past medical history, physical examination and behavioural response to examination.
– Previous investigations and patient’s understanding.
– Previous and current treatment, including response, specialist treatments, side-effects, misconceptions, fixed beliefs, messages from other health professionals.
– Low mood, anxiety or depression.
– Psychiatric history.
– Alcohol and illicit drug use, misuse, dependence or addiction.
– History of physical or sexual abuse.
– Loss of confidence or motivation, reluctance to modify lifestyle, unrealistic expectations of self and others.
• Social assessment
– Ability to self-care.
– Occupational performance.
– Influence of family on pain behaviour.
– Dissatisfaction at work.
– Secondary gain (family overprotection, benefits, medicolegal compensation).
A pain intensity scoring mechanism – either a visual analogue score or a numerical scoring system – is essential. You may recommend a pain diary. This will play an important part of assessment, goal-setting and regular review.
How will I set goals?
Simple goal-setting is very important. We must realise that most of these patients will not get total relief from their pain – it is actually quite good to get a 50% reduction – so goals must be realistic and achievable. Medicines are only a small part of the total treatment and patients often need to stop focusing on the pain and learn to live with it.
Ask what the patient thinks they can do to better manage their pain and discuss options for times when the pain is particularly bad.
You may find the videos in the pain toolkit on paintoolkit.org/tools useful.
Write down the agreed goals and management plan and ensure your patient has a copy. Book a follow-up discussion – make it a specific date and time rather than allowing it to be dictated by pain levels.
What treatments will I offer?
Treatment often requires a holistic approach. Be aware that both relaxation and exercise could be valuable to your patient. Reach out to local providers. You could, for example, refer patients to yoga, Pilates or other exercise classes, or perhaps aromatherapy and relaxation classes.
All community pharmacies stock a range of analgesics, but consider what treatments you could offer that help the patient cope with their pain. These might include rubefacients and topical NSAIDs, cold and heat treatments and transcutaneous electrical nerve stimulators (TENS) or electromagnetic treatments (see pages 36-40 for more on how to audit patients on pain treatment).
When you are recommending analgesics:
• Agree the goals of therapy, such as reduction in pain, improvement in mood or function, and focus on what your patient will be able to do if the pain is reduced by 25% or 50%.
• Agree the length of the initial trial and be willing to change within the analgesic class or combine analgesics if appropriate.
• Discuss the potential side-effects of all treatments offered.
• Discuss the significant risks of specific drugs, especially NSAIDs and opioid medicines.
Consider using leaflets like the one from the British Pain Society, which can be accessed here.
Financial and clinical risk
The most valuable resource in a pharmacy is time. Engaging the whole pharmacy team may spread the load and increase the value of the service. Helping patients with chronic pain will build customer loyalty and respect. A pain service may help the pharmacy reach MUR targets and increase sales of appropriate treatments.
Pharmacists must ensure that they have the appropriate knowledge and skills to run a pain service. The Centre for Pharmacy Postgraduate Education (CPPE) has produced a consultation skills practice pack for pharmacists, which it updated in 2015. It still remains a fundamental skill for any pharmacist wishing to operate new services. The CPPE also recently introduced a pain management e-learning resource.
There are additional packages on addiction, misuse and dependency with a focus on both OTC and prescribed medicines, palliative care and back pain.
Courses are also available for medicines counter assistants who need to be able to differentiate patients with short-term pain from those who have chronic pain so they know which patients to offer advice to and which to refer to the pain service.
There is a wide range of training materials available in pharmacy magazines and clinical journals. As your expertise grows, remember to create a learning portfolio for you and your staff.
The final word
Community pharmacy is not just about treating illnesses with medicines. Sometimes it is about helping people to cope with their condition in a better way, which may include the use of medicines. In the NHS England document Next Steps on the Five-Year Forward View, there is a very small mention of creating health. Community pharmacy has embraced the healthy living concept through health and wellbeing hubs. Helping people with chronic pain live better lives is an important service to offer customers.
Mark Robinson is director of the Medicines Management Partnership and NHS Alliance special adviser on community pharmacy
1 Fayaz A, Croft P, Langford R, et al. Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. BMJ 2017 available at bmjopen.bmj.com/content/bmjopen/6/6/e010364.full.pdf
2 Addiction to prescribed drugs is UK ‘public health disaster’. New Scientist 2016 available at newscientist.com/article/2110089-addiction-to-prescription-drugs-is-uk-public-health-disaster
3 Centre of Pharmacy Postgraduate Education (CCPE) Pain management available at cppe.ac.uk/programmes/l/pain-e-01/
4 NHS England. Next steps on the Five-Year Forward View 2017 available at england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf