Pharmacy and chronic pain management
Some 10 million Britons suffer with pain almost every day, which affects their ability to work and their quality of life. Would a formal pain service in pharmacy be a good idea?
The management of pain places a huge burden on NHS resources, with the number of patients seeking help for chronic pain increasing due to our ageing population. Back pain alone is thought to cost the exchequer Â£5 billion a year, while 9.4 million working days a year are estimated as lost to rheumatoid arthritis. It is suggested that there is a strong case for pharmacies to contribute more to cost-effective and timely pain management services.
â€œPain assessment and management is a service that lends itself well to pharmacy,â€ says Mandeep Mudhur, head of marketing and professional development at Numark, which offers a pain management service. â€œPatients increasingly have problems with pain management, especially with the growing elderly population. There is a plethora of products available in pharmacy, and they can help reduce the workload of GPs, leaving them to focus on more serious cases. There are lots of pain relief aids they can offer, too, such as TENS machines and mobility aids. Itâ€™s not just medication.â€
Dr Christine Haseler, a GP and Arthritis Care UK spokesperson, says: â€œPain services run by pharmacies would be really useful for the public and it would put pharmacistsâ€™ skills to good use, too. Pharmacy staff see their customers in their daily lives and see how they operate and what their difficulties may be. A formal pain service would work best, rather than just making it part of an MUR, which is only one facet of pain management.â€
There are a number of projects that have looked into the potential role of community pharmacies in chronic pain management. University College London worked with Green Light Pharmacies in east London, using an extended MUR model to look at whether patients were being treated for the right kind of pain. A more detailed MUR summary was then sent to the GP if it was felt additional medication was needed, or if it needed adjusting. Pharmacists would also signpost patients to local services/charities to encourage self-management.
In Scotland a â€œteach and treatâ€ model has been used to upskill community pharmacists to assist in the management of chronic pain. Links with NHS services are clearly made and there is an option to refer patients to specialist services where needed.
Pharmacist Chris Rose ran a pain clinic from his pharmacy in Essex. An independent prescriber and pain specialist, he saw patients for six months to help them improve their pain control.
â€œIt increased footfall of customers significantly,â€ he says. â€œI dispensed 70 per cent of that which I prescribed in my pain clinic. It kept patients in primary care and avoided a costly secondary care referral for the GP. Patients had a 20-minute appointment and referral to physiotherapy, if needed. Working together with other services was key, and it definitely improved relationships with local GPs, too.â€
The patients Mr Rose saw in his clinic mostly had musculo-skeletal pain, while some had neuropathic pain. â€œThe idea of my clinic was to try and prevent pain becoming chronic, but in practice I was mostly treating people with chronic pain,â€ he says.
Pharmacy-led pain management services
At the British Pain Society, consultant in pain medicine Dr Austin Leach believes pharmacyled services could be useful to patients. â€œHow successful they are will, of course, depend on how involved staff are,â€ he says. â€œThey need to provide lots of patient education. It needs a pharmacist with a keen interest in pain control and should cover all aspects of pain management, not just drugs.â€
He says musculo-skeletal pain will be the most common type of pain encountered and itâ€™s important to discuss lifestyle factors that will affect this, such as diet and weight loss. â€œYou also need to look at drug interactions because those with chronic pain often have other conditions for which theyâ€™re taking medication. Pharmacy staff have the time to explain this to their customers and itâ€™s an important role.â€
Numark offers a pain assessment and management service and supports any of its members who want to run a service. They are given information and advice on how to structure a triaging service, access to information and products they can recommend. â€œWe also give them advice on pain relief equipment they can use, such as TENS and mobility aids,â€ says Mr Mudhur.
Hundreds of Numark members now offer this service. â€œYou need to devote time and support if youâ€™re going to offer it, but it does bring increased loyalty and footfall,â€ he says.
Spend more time discussing childrenâ€™s headache with parents
There is a need for more effective consultations about childrenâ€™s headache in community pharmacy, it has been suggested.
Headaches in children are prevalent, but their impact can be under-recognised by parents and healthcare professionals, says pharmacist Christine Glover, discussing the findings of a new survey into childhood headache.
While it is estimated that about 60 per cent of children and adolescents have experienced headache and eight per cent of children have had migraine, 28 per cent of pharmacists said they had never spoken to parents about headaches in children in research conducted by the Royal Pharmaceutical Society on behalf of RB, manufacturer of analgesic brand Nurofen for Children.
Headaches are a prevalent problem for children and parents need reassurance, says Ms Glover, past president of the Royal Pharmaceutical Society of Great Britain. Community pharmacy staff have a key role when dealing with queries about childhood headaches, but they may not recognise the predominance of headaches in children or be confident enough to consult parents on the topic.
â€œAsking the correct questions is key in managing childhood headaches and identifying potential red flags,â€ she says. â€œBe aware that self-selection straight from the shelf can limit the opportunity for interaction.â€
When presented with a childâ€™s symptoms in a scenario, community pharmacists were more likely to consider trauma, injury, infection and stress than headache as the source of pain, research has shown, suggesting it is under recognised. When surveyed, parents said headaches can have a large impact on their childâ€™s life, altering their mood (54 per cent) and reducing their confidence (15 per cent), as well as disrupting their school work (38 per cent), activities and trips (23 per cent) and their relationships with friends (14 per cent).
In terms of treatment, Dr Ishaq Abu-Arafeh, consultant paediatrician and chairman of the child and adolescent committee of the International Headache Society, advises: â€œThere are lifestyle measures you can suggest to parents, but it is important to recommend treating patients with an age-appropriate analgesic and to take the highest recommended dose when headaches occurâ€. In addition to offering analgesics, the severity and frequency of headache may be reduced by changes in lifestyle and diet, such as maintaining hydration, regular meals, exercise and sleep, limiting screen time, and avoiding caffeine and sugary drinks, it is suggested. A headache diary can also be useful to help monitor progress.
Dr Haseler emphasises how important it is to listen to your customers when discussing pain. â€œIf a customer says they are â€˜in pain all the timeâ€™ that might not be what they mean,â€ she says. â€œYou need to ask careful questions. Is pain worse at night or during the day? When they exercise or sit still? Get them to describe their pain in detail and how it affects them. How long does it last? And what is their mood like?â€
LloydsPharmacy also has a pain management service, offering a one-to-one consultation with a pharmacist or member of the healthcare team. The pharmacy service is for people with acute or chronic pain.
Emma Davies, an advanced pharmacist practitioner in pain management, says proper training is essential to ensure a safe and effective service. â€œIt is essential that links with local specialists are made, the community pharmacist is aware of local and national guidelines in pain management so they donâ€™t give conflicting advice and, most importantly, that there is an understanding of the complexity of chronic pain so that people who need additional support or are displaying symptoms of other conditions are not missed.â€
She has this advice regarding the advice to give to customers seeking help on pain relief:
- Be aware of the local and national guidelines on pain relief
- When dispensing prescription analgesics, question patients receiving long-term medications for pain to ensure they are effective and still needed
- If you see people who are on multiple opioids, such as tramadol and co-codamol, you should flag this up with the patient and GP, undertake MURs and then provide advice on rationalising medicines
- Give advice to patients taking neuropathic medicines that require titration on how to do this effectively
- Ensure that patients understand that pain relief medicines should be used for relatively short periods (eg three months) and that a review of their effectiveness should be undertaken and the medication continued only if it is reducing pain levels.
Build a better pain management category
Jillian Watt, marketing director at Mentholatum, offers the following three-stage advice for building a better pain management category in pharmacy:
- Signpost the hot, cold and anti-inflammatory pain relieving sections and offer educational leaflets
- Ensure all your staff know when and how to use various types of analgesics, including topical analgesics
- Educate customers about the fact that topicals can offer an effective alternative to orals, delivering targeted relief. Latest in the Deep Heat range is Deep Heat Muscle Massage Roll-On lotion, a drug-free solution to ease knotted muscles when combined with massage. Pharmacy teams can find out more about pain management at the British Pain Society (britishpainsociety.org) and Arthritis Care (arthritiscare.org.uk)
Rena Dadra, Village Pharmacy, Harlington â€œThis is one of the most important categories in our pharmacy. In fact, because of this, we have recently revamped our first aid and pain management section and made it much more prominent â€“ its now easier for customers to find, and more straightforward for them to navigate. We do well with all the pain management products and brands that you would expect â€“ ibuprofen and Deep Heat, for example. In the future I would like to reposition this category at the front of the pharmacy to make it even more accessible to our customers.â€
Fiona McElrea, Whithorn Pharmacy, Dumfries and Galloway â€œThis is definitely one of our more important categories. We mostly sell generics, but some people do come in who want specific brands, such as Solpadeine, Nurofen and Migraleve. Some products have the potential to be abused, which is difficult to police. You give people the right advice and hope they are using the medicines responsibly. The counselling aspect is the most important thing to get right. Ask the usual WWHAM questions, find out what kind of pain the customer has, what products might be appropriate and whether they have already tried anything.â€
Bina Patel, Kalsons Chemist, Westcliff-on-Sea â€œThis is quite important for us, as I used to be a chronic pain and acute pain pharmacist in a hospital. Local hospital waiting lists are increasing and, because of my knowledge of pain management I tend to manage a lot of the GP patients as well. The GPs write â€˜take as directed by the pharmacistâ€™, and I then take care of the changes of dose and so on. Acute pain is something that you can treat with a couple of tablets to solve the immediate problem, but really you need a holistic approach to explore its causes and consider components such as psychological and social issues.â€