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Gloucestershire’s pain transformation programme focuses on optimising analgesic prescribing through medicines management as part of a wider initiative to improve pain services.
“Our programme aims to prevent problems from emerging and to ensure the appropriate use of opioids and other analgesics,” says Dr Cathy Stannard, consultant in complex pain and pain transformation programme clinical lead at NHS Gloucestershire CCG. “Pharmacists, as the experts in medicines management, are central to our programme.”
About 28 million adults in the UK suffer from chronic pain – generally regarded as pain that lasts for more than three months.1 A meta-analysis of 19 studies reported that between 35.0-51.3 per cent of people endure chronic pain, with between 10.4-14.3 per cent experiencing moderately to severely disabling chronic pain.1 However, rather than set an arbitrary time at which pain becomes chronic, Dr Stannard suggests considering whether the duration is abnormal given the pathology.
“Experiencing pain a week after a mild groin strain is normal but if the person is still in pain a month later, that is abnormal and warrants further investigation. Pain that is distressing or disabling and which is not associated with obvious injury needs evaluation, whether or not it has lasted for three months.”
Many people in chronic pain rely on opioids to alleviate their distress. According to NHS data, opioid prescribing rose by 64 per cent between 2006-16. A recent editorial in the British Journal of Clinical Pharmacology traces the roots of the “dramatic increase in opioid prescriptions” to the under-diagnosis and under-treatment of severe pain during the 1980s.
“The titrate-to-effect model for analgesia in acute, cancer and end-of-life pain that expanded to encompass other types of pain was driven by aggressive marketing and vociferous advocacy,” the authors comment. This “cultural transformation” occurred “despite insufficient evidence that long-term opioids improve chronic pain or function and ignored the robust evidence of dose-dependent serious harm,” they say.2
Opioids contribute to thousands of deaths each year. In 2016, 3,744 death certificates in England and Wales mentioned illegal or legal drugs. Drug misuse accounted for 69 per cent of these deaths and 54 per cent involved an opioid.3
The Advisory Council on the Misuse of Drugs (ACMD) says the number of opioid-related deaths in England rose by 58 per cent between 2012 and 2015, while there were increases of 21 per cent in Scotland, 23 per cent in Wales and 47 per cent in Northern Ireland.4
Unfortunately, death certificates do not indicate whether an opioid was prescribed, bought OTC or obtained illegally4 – i.e. either on the street or by diversion from a legitimate source. (Diversion refers to opioids that may be used to treat someone else’s pain or anxiety and, much less commonly, to get high.)
Despite the focus on the ‘opioid epidemic’, most of the increase in opioid-related deaths over recent years seems to reflect the premature ageing of people who have used heroin since the 1980s and 1990s.4
In 2016, 184 death certificates in England and Wales mentioned tramadol – down from a peak of 240 in 2014.3 This reduction may reflect, in part, changes to tramadol’s legal status (it was reclassified as a Class C drug in 2013 and a Schedule 3 drug in 2014 limited to 30 days’ supply)2 but, putting these figures in context, 219 death certificates in 2016 mentioned paracetamol, 75 oxycodone and 58 fentanyl. Forty-five death certificates mentioned propranolol, which is prescribed for anxiety as well as angina, hypertension and migraine.3
According to the ACMD, 70 per cent of tramadol-related deaths in England and Wales involved another substance, usually alcohol (36 per cent), antidepressants (32 per cent) or heroin (27 per cent).4 The high proportion of deaths that also involve antidepressants may indicate mortality from prescription tramadol, the ACMD says, and might also signify the high proportion of emotional and psychiatric co-morbidity among people using tramadol.
Services need to explore innovative approaches to help people who experience difficulties stopping opioid analgesics, says Dr Stannard, citing the example of a worker from the drug and alcohol services team in South Gloucestershire CCG, who counselled people who overused prescription opioids.
“The drug worker took a holistic approach,” Dr Stannard recounts. “He helped people resolve issues over, for example, housing and finances. This ‘social prescribing’ proved fantastically successful and patients came off the opioids. The work is currently unpublished, but it is an approach that we need to harness.”
Dr Stannard feels that professional education is the cornerstone of improving pain management in the community. Her CCG runs masterclasses aimed at GPs, pharmacists and other members of the primary care team. “We incentivised the class financially, which ensures a good turnout among GPs,” she says, “but the meetings have also been really well attended by pharmacists.”
Pharmacists have been among the most “enthusiastic” healthcare professionals when it comes to addressing inappropriate analgesic prescribing, she says. “They seem to feel this is an area where they can make a real difference.” For example, a pharmacist in the pain transformation team identified everyone in the county on potentially hazardous analgesics – such as high-dose opioids, multiple opioids and opioids in combination with other centrally acting drugs (e.g. gabapentinoids and benzodiazepines) – which helped ensure they would be reviewed.
Pharmacists are central to the pain transformation programme run by Gloucestershire CCG. A prescribing support pharmacist reviews the clinical records of people prescribed opioids and segregates patients into three risk levels:
• Lowest risk includes those people taking tramadol plus codeine or dihydrocodeine
• Middle risk includes, for example, those taking a strong opioid plus tramadol or codeine or both
• Highest risk includes users exceeding an oral morphine equivalent dose of 120mg daily (e.g. fentanyl patch 37mcg an hour or 30mg modified-release oxycodone twice daily), or any strong opioid plus gabapentin or pregabalin plus a benzodiazepine with or without an antidepressant.
The prescribing support pharmacist consults with the lowest risk patients and appropriate people in the middle risk group to determine if the analgesics are effective. If appropriate, the pharmacist and the patient agree deprescribing, such as tapering the dose and moving to self-management.
The pharmacist refers the remainder of the middle risk group and all patients at highest risk to a clinical pharmacist, who is an independent prescriber, who either discusses deprescribing or refers to a GP for a review. In turn, the GP can discuss deprescribing or refer to a pain clinic. The aim, whenever possible, is to deprescribe.
“If necessary, pharmacists can draw on the expertise of GPs and other healthcare professionals,” Dr Stannard says. “Pain is often a complex problem that needs a multidisciplinary approach. Pharmacists are well aware of their limits of expertise.”
Pharmacists focus on optimising current drug use, which is often an important advantage compared to the consultation style of many GPs. “The need to ‘do something’ to alleviate a patient’s distress is deeply embedded in GPs’ philosophy,” Dr Stannard says, “so it is difficult for them when not prescribing might be the best approach. GPs also tend to think of all the potential implications and the longer-term prognosis. Pharmacists are much more focused on optimising current treatment. That is a lesson that, sometimes, GPs should learn.”
Input and education from mental health professionals can prove invaluable to structure a consultation and make transactions and agreements with patients, adds Dr Stannard. As an example, she highlights the importance of setting expectations at the initial consultation by explaining that analgesics generally help only about a quarter of people in chronic pain.
“Educating and informing patients about self-management and the need for safe analgesic prescribing can prevent problems later on,” she says. “The prescriber needs to explain why a drug is or isn’t appropriate, the risks and what alternatives exist.”
Initially, Dr Stannard says, some specialised pain services expressed concern about whether deprescribing programmes in primary care would work but it is now clear that pharmacists and other members of the primary care team can triage patients before referral to over-stretched specialist services.
In addition, the programme in her area has saved £500,000 in prescription costs on opioid analgesics alone. Prescriptions for other analgesics – including pregabalin and gabapentin – also declined but these are used for a variety of indications, so discerning the impact of the pain programme is difficult.
“Hopefully, we’ll be able to use the savings to help make a business case for a wider service redesign, which is obviously a lot harder than just focusing on prescribing,” Dr Stannard says. “The NHS is generally so focused on immediate problems and the current budget that we often underestimate the importance of investing to save. We need to explore ways to further reduce the pressure on secondary care by optimising primary care services by pharmacists, GPs and other members of the team.”
Dr Stannard admits that her status as a world authority on pain management helped drive the service but she still stresses the importance of engaging with other local stakeholders. “We have a very enthusiastic and innovative commissioning team in Gloucestershire CCG, who are keen to showcase our programme nationally,” she says. “Their support has been vital to the programme’s success.”
Dr Stannard believes the combination of increased awareness about inappropriate analgesic prescribing, partly highlighted by the North American experience, and the need to contain rising prescribing costs means that analgesic use for chronic pain has reached a tipping point. “Prescribing analgesics appropriately isn’t just important clinically, it is also about good stewardship of NHS resources,” she says. “We are at a tipping point where the management of chronic pain is set to change.”
For example, NICE guidelines on the management of back pain, published in 2016, moved away from prescribing opioids and towards advocating self-management, exercise and, when appropriate, psychological approaches. According to the guidelines, a non-steroidal anti-inflammatory drug (NSAID) should be prescribed for low back pain at the lowest effective dose for as short a time as possible. Prescribers should not offer opioids routinely for acute low back pain but weak opioids, with or without paracetamol, may be appropriate if a NSAID is contraindicated, poorly tolerated or proved ineffective.
According to the guidelines, prescribers should not offer opioids for chronic low back pain, or paracetamol alone, or anticonvulsants for low back pain generally. “The back pain guidelines helped bring the messages about appropriate analgesic prescribing to the fore,” Dr Stannard says.
In 2020, NICE plans to issue clinical guidance covering the management of chronic pain, which should help drive further improvements. In the meantime, pharmacists can help enhance local services. “The basic information about analgesic use is well established in the literature and there’s really no reason why other CCGs could not emulate our success,” Dr Stannard concludes.
“After all, it is about doing what we know we should be doing already. We know that in some cases, the most appropriate treatment for chronic pain is to stop or not offer drugs. And we know that GPs and patients recognise that pharmacists are the experts regarding medicines. This means that if a pharmacist suggests the most appropriate approach for chronic pain is to stop analgesics, GPs and patients tend to listen.”
Pain, emotion and social rejection seem to share many of the same pathways in the brain. In one study, 62 healthy undergraduates took paracetamol or placebo daily for three weeks. Compared to placebo, paracetamol reduced daily reports of social pain (e.g. “Today, being teased hurt my feelings”).
Functional magnetic resonance imaging (MRI) revealed that paracetamol reduced neural responses to social rejection in brain regions (specifically the dorsal anterior cingulate cortex and anterior insula) that previous studies had associated with the distress caused by social pain and with the emotional component of physical pain. For example, patients with damage to these areas still feel pain, but they are “not bothered” by the stimuli.5
Another study performed functional MRI on 40 people who recently experienced an unwanted break-up. Researchers imaged the brain when the volunteer looked at a photograph of their ex-partner and thought about being rejected as well as when they received a painful heat stimulus. Looking at a picture of a friend and a warm sensation respectively acted as controls.6
The researchers found that brain areas involved in the sensation of physical pain (the secondary somatosensory cortex and dorsal posterior insula) became active. Physical pain induced by heating activated the same areas of the brain. Indeed, rejection and heat induced a similar level of subjective “pain”.
When the authors analysed 524 studies, activation of these regions “was highly diagnostic of physical pain”. The positive predictive values were between 74 and 88 per cent depending on the brain region.6 Just 12-26 per cent of the predictions based on brain scans were false positives.
This overlap between social and physical pain makes evolutionary sense. Humans need constant care and supervision for at least the first couple of years of life, so rapidly developing social connections is critical for an infant’s survival. The pathways responsible for social attachment “may have evolved by piggybacking directly onto the physical pain system to promote survival”, the researchers comment.5
In other words, the association between emotional distress and physical pain is hardwired into our brains – which might help explain why some people manifest emotional distress as chronic pain. Indeed, medically unexplained symptoms, which encompass many cases of chronic pain, account for up to 40-50 per cent of consultations in primary care and up to half of those in secondary care.7
Opioids are, of course, potent anxiolytics and numb emotional distress – but they just paper over the emotional cracks in users’ psychological defences. “People in chronic pain don’t commonly use opioid analgesics to attain a ‘high’, but to blunt emotional trauma,” Dr Stannard says.
“They use opioids to self-medicate their emotional needs. Patients start using opioids to alleviate pain. They keep using them to help them get through the day. You need to drill down into the psychology of a person taking opioid analgesics. Often you’ll find domestic violence, a history of sexual or physical abuse, or another emotional trauma. You can then refer the patient to counselling, psychotherapy, an addiction service or another appropriate service.
“Many healthcare professionals and patients don’t appreciate the complexities of chronic pain,” Dr Stannard adds. “Chronic pain is relatively easy to understand if it arises from osteoarthritis. If the chronic pain is out of proportion to the underlying pathology or there is no tissue damage or organic process, then the pain is usually a somatic expression of the patient’s emotional distress.
“That doesn’t make the pain any less ‘real’ to the patient but it is a different problem to that posed by the pain of osteoarthritis. Pharmacists and other healthcare professionals need to look behind the report of pain to discover the cause and the most appropriate approach to management.”
Pharmacists as the experts in medicines management are central to our programme
1. BMJ Open 2016; 6:DOI: 10.1136/bmjopen-2015-010364
2. British Journal of Clinical Pharmacology 2018; 84:813-815
3. ons.gov.uk/peoplepopulationand community/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandand wales/2016registrations:
5. Psychological Science 2010; 21:931-937
6. Proceedings of the National Academy of Sciences 2011; 108:6270-6275
7. BMJ Open 2017; 7:DOI: 10.1136/bmjopen-2016-014720