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