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Pain management: Misery for millions

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Pain management: Misery for millions

At any one time, around one million people in this country are suffering from pain that could be much better managed. Improving the lives of these people requires a painstaking approach by pharmacy teams...

 

Learning objectives

After reading the case studies in this feature you should be able to:

  • Identify those patients who require help with their pain management
  • Advise on the correct dosage and duration of pain relief medication
  • Provide lifestyle tips that will aid in the management of pain.

 

Effective management of pain needs to be tailored to the individual person taking into account, for example, the patient’s age, medication history and the presence of contraindications. Outlined below are some potential scenarios regarding pain management. What would you advise?

A middle-aged man experiencing muscular pain as a side-effect of statins

Statins are known to be well tolerated, effective agents and a growing number of patients take them. Last year, NICE lowered the risk threshold for primary prevention of CVD from 20 per cent to just 10 per cent, which meant an additional four to four-and-a-half million people became eligible to take statins. If even a small percentage of these patients experience adverse events, the numbers are considerable.

Both real and perceived adverse effects can undermine adherence and, as a consequence, hinder the potential lifelong benefits of these agents. Adverse effects of statins largely comprise myopathy, muscle aches or myalgia, weakness, stiffness and cramps. These effects may or may not be accompanied by elevations in serum creatinine. According to the 2015 European Atherosclerosis Society consensus statement on statin-associated muscle symptoms, pain and weakness associated with statins tends to be symmetrical and proximal, usually starting within four to six weeks of statin initiation.

“One of the first things I’d do is check the patient has informed his GP if he is having problems,” says Emma Davies, advanced pharmacy practitioner in pain management, South Wales, and chair of the UKCPA pain management group. “I’d take a relatively quick history: When did the pain come on? Is there a link to statin use? Are we sure it is the statins and not potentially something more sinister? If he hasn’t seen his GP, then he needs to do so.”

She suggests that OTC analgesia might help. “I’d tend towards paracetamol rather than an NSAID. If the patient is on a statin he could have a CV condition and we wouldn’t want to use an NSAID in this case. Alternatively, non-medication methods such as heat or ice might be used.”

Community pharmacist Valerie Sillito agrees and says that, while advising the patient to see his GP, she would also offer simple painkillers such as paracetamol in the short-term. “The patient is probably taking the statin for a heart condition and, as a pharmacist, you are not in a position to stop it. Tackle the acute problem first, and advise the patient to go to his GP and check whether the statin is causing the pain.”

Recommended approaches to poor tolerance to statins include reviewing the statin indication and any contraindications, emphasising lifestyle measures for lipid modification and use of non-statin pharmacotherapies, and re-challenging with the same or an alternate statin if the first statin is stopped.

Lee Wilson, consultant pharmacist, pain management and peri-operative care at Doncaster and Bassetlaw Hospitals NHS Foundation Trust, warns that, “adjuncts such as co-enzyme Q10 or vitamin D are not supported by the evidence base”.

A desk worker suffering from lower back pain and stiffness

Lower back pain is one of the commonest problems in adults, affecting most people at some point in their life. It can be triggered by bad posture when sitting, standing or lifting and usually resolves within weeks or months, although it can be long-term or recurrent. Valerie Sillito emphasises the importance of a basic history: “Ask the patient to describe the pain, how long it lasts, associated symptoms and then find out about any medications they’ve tried.”

A number of simple measures may help to prevent or reduce lower back pain among office workers, including altering posture periodically by standing, control of body weight and exercises to enhance skeletal muscle mass. Simple analgesics may also help; research suggests that topical NSAIDs may be preferable to oral formulations in terms of both efficacy and tolerability.

“I’d recommend straightforward painkillers, such as paracetamol, for back pain caused by desk work,” says Sillito. “Alternatively a non-steroidal gel or a hot rub may help. Advise the patient to get their sitting position checked at work by their health and safety/occupational health department.”

Office workers need to get up from their desk from time to time, says Emma Davies. “Strategies that I offer to patients include standing up when they are on the phone and sitting down while they are on their PC. This gives them the opportunity to alternate while working. They might want to have the kind of chair they use looked at, and the ergonomics round their desk might need a review. Most businesses offer some kind of occupational support.”

Non-medication management options, such as wheat bags or hot water bottles, might be preferable, she says. “If the patient sits for long periods of time, a hot water bottle behind the back may help. This can also improve their sitting position by pushing them forward a bit. Non-medicine strategies are more effective in the long-term.” She also highlights the benefits of exercises, particularly stretches, and recommends NHS Choices as a good site for advice.

Lee Wilson agrees that non-drug management is important in this scenario but would first rule out a neuropathic pain component. “Simple analgesics might be helpful here but I would try to avoid opioids, including weak opioids, as they may aggravate any constipation.”

Office workers will often suffer from back pain due to the sedentary nature of their jobs

A jogger hobbling into the pharmacy with an acute ankle sprain

Ankle sprains are a common problem, particularly among teenagers and young adults. Most are caused by inversion injuries to the lateral ankle ligaments.

Emma Davies recommends rest, ice and elevation. “We also used to recommend compression but tend not to advise this for acute injuries now. Inflammation is part of the natural healing process and there is a risk that strapping the injury can impair this. External support can lead to a change in gait to compensate which, in itself, can cause a different type of injury. Many athletes use tape now. Tape can enhance the support of the natural musculature.”

Exercise and rehabilitation should be encouraged to strengthen the natural skeleton, which is more likely to have a better effect in the long-term, she adds. Simple analgesics – paracetamol or ibuprofen – can be recommended if the injury is particularly painful. A NSAID gel or freeze spray with anti-inflammatory properties might also help.

“Tell the patient to stay off the ankle as much as possible for the week following the injury to allow the inflammation to go down,” she says. “If it hasn’t improved or has got worse after a week, they should see their GP or attend a local physio centre. Try to de-medicalise the injury as much as possible and concentrate on functional rehabilitation.”

A previous ankle sprain is the greatest risk for an acute ankle sprain, so patients should be counselled about preventing further injury. Preventative measures, particularly for those involved in sport, might include ankle supports, taping, neuromuscular training and sport-specific warm-up exercises.

A teenage girl struggling to manage dysmenorrhoea

Primary dysmenorrhoea refers to menstrual cramping typical of ovulatory cycles. It is important to rule out secondary causes by finding out, for example, when the symptoms started in relation to menarche and finding out about any other gynaecological (e.g. menorrhagia, intermenstrual bleeding) or nongynaecological symptoms (e.g. rectal pain may be associated with endometriosis).

If secondary causes for dysmenorrhoea are excluded, pharmacological options include NSAIDs such as ibuprofen or naproxen, mefenamic acid, or paracetamol instead of NSAIDs (in case of contraindication) or as well as NSAIDs if there has been an insufficient response. There is some evidence to suggest that NSAIDs are more effective if they are taken proactively, rather than as a response to already-present pain. It is important to ask about any chronic diseases that may be contraindications, such as asthma.

“Simple NSAIDs are likely to be the analgesic of choice for dysmenorrhoea once contraindications have been excluded,” says Lee Wilson. “It might be worth noting that the patient may be asthmatic but with no sensitivity to NSAIDs. The absolute incidence of bronchospasm is low, around five to 10 per cent, but perceived to be higher.”

Should medication be needed, it is best to start with something simple like paracetamol, ibuprofen or naproxen, says Emma Davies. “This can be stepped up to mefenamic acid, which is taken a couple of days before the period starts and continued throughout the period. It can also help to reduce blood loss. Being prescription-only the patient would need to be prescribed mefenamic acid by her GP. Hyoscine (e.g. Buscopan) may help if cramping is the predominant symptom.

“Generally, a combination of medication and non-medication methods is best,” she says, emphasising the value of nonmedication approaches such as use of a hot water bottle, stretches and simple exercises.

“I may suggest going to the GP, who may recommend oral contraceptives to control bleeding and help to regulate the pain,” says Valerie Sillito. Possible benefits of combined contraceptives include regulation of the cycle, reduced flow, reduced cramps and beneficial effects on acne and hirsutism. Misinformation surrounding oral contraceptives abounds, so it is important to reassure young women and/or their parents about the relative risks for weight gain and cancer.

A middle-aged woman with mild shingles pain

Shingles (herpes zoster) results from the reactivation of the varicella zoster virus, the cause of chickenpox, with diagnosis usually based on its distinctive rash – blisters or vesicles on the upper trunk. Reactivation of the virus often accompanies impaired immunity secondary to ageing or immunosuppression.

Up to a third of people with shingles will be subject to complications, most commonly post-herpetic neuralgia, with pain lasting more than three months following healing of the rash. The risk of this debilitating complication is increased with each decade of life after the age of 50 years.

Early recognition and treatment of shingles can reduce symptoms and may also help to prevent progression to postherpetic neuralgia. Treatment options for shingles include antiviral therapy and pain medications. Oral antivirals, such as aciclovir, reduce the period of viral shedding and the duration of the rash, as well as the severity and duration of acute pain and the risk of progression to post-herpetic neuralgia. They are safe and well-tolerated.

“Antivirals tend to help the resolution of shingles more quickly, address pain at an early stage and stop escalation,” says Emma Davies. “Alternatively, a short course of amitriptyline or gabapentin may be tried. Advise the patient to see her GP and ask about the suitability of these options.”

An elderly woman with OA of the knee who is already on numerous medications

A large UK study has reported that inadequate pain relief is common among people with knee osteoarthritis and tends to be frequently reported in women.

As polypharmacy is common among the elderly, a pharmacistled medication review can be invaluable. Research suggests that such reviews in chronic pain management reduce the intensity of pain, as well as improving both physical functioning and patient satisfaction.

“It is important to review what has been helpful previously, discontinuing products that have been used as a regular treatment with no effect and rationalising any bizarre combinations,” says Lee Wilson.

Emma Davies agrees. “A polypharmacy MUR will determine if she needs all of her medications. See if there are any other agents that she is taking that might be contributing to the pain – for example, statins or corticosteroids – and check if there are any other conditions that might be contributing. Is she already taking analgesics?”

NSAIDs are known to be effective for pain management in osteoarthritis but they can also have an effect on the gastrointestinal, cardiovascular, hematologic, hepatic and renal systems. As topical NSAID formulations are associated with fewer adverse events, EULAR (European League Against Rheumatism) guidelines specify that they should be given preference over oral NSAIDs for knee or hand osteoarthritis of mild to moderate severity and few affected joints, as well as to those with a history of sensitivity to oral NSAIDs.

“The current advice is to offer simple analgesics, such as paracetamol, and topical NSAIDs ahead of systemic NSAIDs,” says Davies. For an older patient with polypharmacy, trying a topical NSAID preparation prior to systemic NSAIDs would be sensible.

“If simple analgesics are not working, move up a step on the pain ladder. Consider adding codeine or dihydrocodeine to paracetamol. Look at alternatives, especially in the case of polypharmacy.”

Non-pharmacological options should always be considered for anyone with osteoarthritis. Those recommended by EULAR include exercise advice appropriate to the individual, weight loss for those who are overweight or obese, advice on footwear, and consideration of appropriate walking aids, adaptations or assistive devices.

Exercises to improve stability and walking nearly always help to reduce the pain. “In these situations, the priority tends to be maintaining function rather than absolute pain reduction,” says Davies. “The most important thing is to keep moving.”

 

Pain counselling tips

A 2013 UKCPA pilot study found that, if enhanced pharmacy-led MURs were scaled up to a national service in England, community pharmacists could identify at least 50,000 cases of neuropathic pain and approximately 10,000 cases of other serious illness involving pain each year. Steps that can help maximise the value and effectiveness of pharmacist interventions in pain management include:

  • Using MURs to optimise drug regimens and rationalise any unnecessary combinations
  • Advising on all aspects of pain management, from protection against overuse of analgesics to medication and non-medication approaches to pain
  • Facilitating multidisciplinary support; for example by advising patients to see their GP
  • Ensuring that patients are on the optimal dose of analgesics, and providing advice when this is not the case
  • Monitoring both repeat prescriptions and OTC analgesics, providing an overall perspective of the combination of the two
  • Recognising that medications are not the only option in pain control and that a combination of medication and non-medication approaches is likely to be the most effective approach.

 Approximately 10m people in the UK experience pain on an almost daily basis

Key facts

  • Approximately 10m people in the UK experience pain on an almost daily basis
  • A 2013 UKCPA pilot study has shown that enhanced pharmacy-led MURs could help identify at least 50,000 cases of neuropathic pain each year
  • A combination of medication and non-medication approaches is likely to be most effective
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