In Clinical
Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.Bookmark
Record learning outcomes
Acute pain is an essential alarm, warning us of potential harm. It is why we instinctively pull our hands away from a hot stove or protect a sprained ankle. Without this warning, injury and damage would often go unnoticed.
“Nevertheless, acute pain is poorly understood and opportunities to improve its management might be missed,” says Dr Emma Davies, principal pharmacist, pain, analgesic stewardship and harm reduction, at the Royal Glamorgan Hospital and member of the British Pain Society.
Awareness of acute pain’s biological importance offers little solace when we stub a toe and unleash a torrent of ‘creative’ vulgarity. But swearing helps – probably by being a distraction and offering emotional release. One analysis suggests swearing increases a person’s pain threshold by 32 per cent and tolerance by 33 per cent compared with a neutral word.1 Such findings underscore the often under-appreciated complexity of acute pain…
Missing opportunities?
The pain of a stubbed toe resolves in a couple of minutes, but sprained ankle pain can persist for days or weeks.2 “Acute pain is sudden or urgent, typically lasting from a few seconds to three months, and is often caused by specific injuries or events,” explains Nisa Masyitah, project and data support coordinator at the International Pharmaceutical Federation (FIP). In January, FIP published a report highlighting the burden imposed by musculoskeletal conditions, including acute as well as chronic pain.3
Davies suggests: “Perhaps the commonality of the condition is a barrier to optimising its management. We all will experience acute pain at some time.” However, she adds: “Being familiar with something is not the same as knowing how to best manage it. It is likely that we are missing opportunities to treat acute pain effectively, particularly introducing non-pharmacological support. Poorly managed acute pain can result in chronic pain, so it is imperative we get it right.”
Inês Nunes da Cunha, FIP practice development and transformation projects manager, believes community pharmacists are uniquely positioned to play a significant role in musculoskeletal pain management. “Patients with musculoskeletal pain often turn to pharmacists for advice on alleviating symptoms,” she says. “By integrating pharmacological and non-pharmacological interventions, pharmacists can provide a more holistic approach, ultimately enhancing patient outcomes and improving quality of life.”
A multi-modal approach combines medications such as over-the-counter analgesics with non-drug methods such as physical therapy, heat or cold application, and gentle exercise, explains Davies. “A holistic strategy reduces dependence on medications alone and can prevent the progression of acute pain into chronic pain.”
“A good pain history is essential before pharmacists reach for analgesics”
Holistic approach
Acute pain management in UK hospitals is improving. For example, around half of adults
undergoing surgery experience significant postoperative pain, which can delay recovery. The British Pain Society and the Association of Anaesthetists recently published peri-operative management guidelines to improve outcomes through a comprehensive, patient-centred approach to pain management.4
“Guidelines for managing acute pain are perhaps less common than we might expect in primary care and community settings,” says Davies. “Some years ago, work was undertaken in Wales to determine pharmacists’ and pharmacy technicians’ knowledge and confidence to manage pain.5 The feedback from community pharmacy was that they were not included in guideline development or provided with copies of local policies on prescribing. It can be harder to challenge prescribing if you are not aware of what is expected in the first place. Better communication across sectors would improve management and support people to manage their pain more effectively.”
One important message is that a good pain history is essential before pharmacists reach for the analgesics. “We can individualise management of acute pain based on an individual’s report of their experience, the problem that is causing the pain and any other medications they are taking,” Davies explains.
“Pharmacists need to listen to the symptoms that a person describes and understand the functional impact. When someone presents, we don’t necessarily know whether this is really ‘acute’ pain. It may be the first time they’ve reported it to a healthcare professional, but it may not be the first time they have experienced the pain. So, we need to take a holistic approach, regardless of presentation.”
Watching for red flags is part of this holistic assessment. “Generally speaking, if someone comes into a community pharmacy, you might assume that they don’t have pain so severe that they can’t function,” Davies says. Nevertheless, pharmacists should be alert for red flags in people presenting with acute pain – such as pain that doesn’t respond to analgesics, poor bowel or bladder function, or lost sensation in the legs in someone with lower back pain, which could indicate cauda equina syndrome (spinal cord compression).6
“It is quite easy to miss cauda equina syndrome in people presenting with low back pain,” Davies warns. “Acute pain and unexpected weight loss should raise the suspicion of cancer.
“In general, pharmacists should refer people with a sudden change in symptoms or a marked increase in pain that they can’t manage with their usual method to their GP rather than A&E. People who attend A&E with acute or chronic pain may be over-investigated and over-treated, especially if the hospital does not have access to their full medical history.”
Davies suggests focusing on function rather than intensity when managing acute pain. “Somebody may come into the pharmacy and say that they hurt their back over the weekend,” she says. “Often, the conversation focuses on how much pain they have. The pharmacist may ask the person to give their pain a score. The aim then becomes to reduce that number. But specialists increasingly recognise that functional improvement should be the main outcome of management of acute or chronic pain. If somebody can do more, it is very likely that the pain intensity has reduced.”
Pain intensity is just one aspect of a complicated experience, and focusing on intensity can be counterproductive: people may escalate medicines because they are not entirely pain-free. Pharmacists therefore need to set patient expectations.
“The term ‘painkillers’ is really unhelpful,” Davies says. “Patients assume that they are aiming at no pain. In fact, we’re aiming at pain reduction to improve function. Healthcare professionals in all settings, including community pharmacy, need to be confident having those conversations.”
A multi-modal approach to pain relief can improve outcomes.
“Functional improvement should be the main outcome of pain management””
Tailoring treatment
Nisa Masyitah says that if no red flags are present, first-line interventions for musculoskeletal pain such as low back pain, neck pain and osteoarthritis include reassurance and education to encourage exercise and staying active.
“Analgesics, oral and topical NSAIDs and muscle relaxants are the most commonly used options to alleviate pain,” Masyitah says. “In addition to newer technologies, such as pulsed short duration therapy devices, heat and cold therapy is widely used to relieve musculoskeletal pain.”
According to Nunes da Cunha: “Evidence supports using topical and oral NSAIDs to alleviate musculoskeletal pain. However, oral NSAIDs may be contraindicated for patients with a history of gastrointestinal or cardiovascular issues. Topical NSAIDs provide localised pain relief at the site of application, which minimises the risk of side- effects associated with oral NSAIDs.”7
“Paracetamol has always been viewed as a fairly innocuous analgesic that should be the baseline medicine for everybody,” says Davies. “It has very few interactions.” However, she says it is not always effective: “NICE guidance for low back pain and osteoarthritis, for example, suggests paracetamol is ineffective as a lone treatment for either condition.”8
Nunes da Cunha agrees: “There is little evidence that paracetamol is effective compared with placebo for low back pain.9 Paracetamol is recommended for neck pain due to its safety profile, despite the weak supporting evidence.”10
“A trial of paracetamol is perfectly okay,” Davies says, “but we shouldn’t insist that people continue taking it if they are saying it really doesn’t do much.”
Furthermore, case reports suggest that older, frail people can come to harm after taking what seems to be a normal paracetamol dosage. “The British Hepatology Pharmacy Group recommends reducing the dose of oral and IV paracetamol in people who weigh less than 50kg,” Davies says.
“That remains quite controversial, however, and I have colleagues who don’t agree with that approach. As a pharmacist, medicines safety is a priority and given the potentially poor effectiveness of paracetamol, I think it is preferable to reduce the dose rather than risk causing harm.”
Pharmacists may also want to think twice about codeine, which Davies believes should be a prescription-only medicine. “For most people, the doses of codeine available in OTC preparations are sub-therapeutic,” she says. “So people often end up taking much more than they should to try to get additional pain relief. We need to consider why pharmacies are still selling a product of limited benefit but known harm.”
OTC codeine can also be misused or used to ‘top up’ other drugs of abuse. For instance, it is easy to use cold water extraction with coffee filters and other household items to separate codeine from ibuprofen or paracetamol.11 “Colleagues in substance misuse work tell me they find it much harder to get people off codeine than most other opioids,” says Davies.
This is partly because of ease of access: it is possible for people to purchase it from multiple pharmacies in quick succession. “People misusing opioids also like codeine,” Davies adds. “Codeine scores highly for likeability, a measure of the positive psychoactive effects of a drug, and can point to its likelihood of misuse and dependence. There seems to be something in codeine that makes it attractive to people with a predisposition to misuse.”12
Non-drug therapy
Nor should pharmacists be giving pain medicines in isolation, says Davies: “They should include non-pharmacological as well as pharmacological options.”
Heat therapy can be effective for musculoskeletal conditions, while cold therapy can help with acute injuries, such as sprains and strains, by reducing inflammation, swelling and limiting blood flow.
Nunes da Cunha cautions that patients should be advised to avoid heat or cold therapy immediately after using topical treatments such as NSAIDs or capsaicin, as this can increase their absorption, potentially causing skin irritation or burns. “Pharmacists should advise patients to apply topical medications two to four times a day, with adequate spacing between heat or cold therapy sessions,” she advises. “This ensures safe and effective pain management, preventing complications while allowing patients to benefit from topical and thermal therapies.”
People with repeated episodes of acute pain may also benefit from counselling or psychological interventions, suggests Davies. “There has been an assumption that psychosocial factors apply only in chronic pain and that the longer you have pain, the more important those factors become,” she says. “But people can have repeated bouts of acute pain, such as recurrent back pain. We know our previous experience of pain will impact our subsequent experiences. If we can give people a more positive experience of acute pain, they are much less likely to progress into chronic pain.”
Nunes da Cunha adds: “Non-pharmacological approaches to musculoskeletal pain include educating patients about, for example, lifestyle modification and knowing when to refer for specialist support. People with musculoskeletal pain need appropriate stretching exercises to relieve and strengthen the muscles, and to give the affected muscles enough rest.”
There has been little therapeutic innovation for acute pain in recent years, which underscores the need to best use the available pharmacological and non-pharmacological treatments. “We still need innovative treatments for acute pain,” says Davies. “Our better understanding of the mediators and genetics underlying acute pain offer great potential for game-changing treatments, but these are some way off.”
Simple interventions elevate patient experiences
A series of simple interventions rooted in behavioural science have been shown to improve pain management experiences in community pharmacy. Research shows they help to reframe patient perceptions, encourage patients to discuss their pain and support better pharmacist-patient consultations.
The interventions were developed by the Haleon Centre for Human Sciences and are now available for
UK pharmacies to access, having been trialled in Australia via the Pharmacy Pain Consultations Programme pilot.
Consumer healthcare company Haleon created the programme after it discovered a need to “drive better pain management”: its 2023 Pain Index survey found that the emotional and everyday impact of pain has grown by nearly 25 per cent in the past decade.
Haleon faculty member, pharmacist Thorrun Govind says: “Patients can often be stuck in a flare-and-fix cycle where they don’t engage with pharmacists around long-term pain management. This can lead to a transactional relationship for pharmacists and incorrectly managed pain for patients.”
The Australian pilot found that Haleon’s in-store prompts and cues elicited a significant shift – from
8 to 21 per cent – in the proportion of patients who saw something that encouraged them to discuss their pain with a pharmacist. And 92 per cent of patients felt prepared to talk about their pain, compared with 71 per cent before the interventions.
The results, measured by Professor Colin Strong, head of behavioural science at IPSOS, also revealed that with the interventions in place, 72 per cent of patients perceived the pharmacy as more than simply a place to pick up prescriptions. Just 41 per cent recognised this beforehand.
The interventions included window posters and floor graphics to disrupt habitual behaviours and reframe patient perceptions of a pharmacist’s role. Additional in-store materials aimed to motivate patients to act if their pain management was inadequate, and streamlined store navigation was designed to help reduce their cognitive load.
“We know that even small cues, such as in-store signs and prompts, can encourage desired behaviour,” says Haleon. “Our patient-facing materials utilise behavioural science techniques to encourage more patients to stop and re-evaluate their pain management and choose to use pharmacy advice for pain relief if they need to.”
For instance, tear-off pads placed at the pain fixture can prompt patients to talk to a pharmacist. Offering up pain management questions, such as ‘what are my options for medications or other treatments?’ creates a sense of personal necessity that prompts patients to talk to a pharmacist for answers, says Haleon.
Marketing director Laura Street explains: “Many patients in pain have established habits of thought and behaviour that prevent them from discussing their pain, evaluating their treatment needs or following clinical advice. We recognise the pressing
need to support pharmacists in fulfilling their potential as holistic healthcare providers.”
As such, Haleon’s programme also includes training modules designed to enhance the confidence and ability of pharmacists to “drive lasting patient behaviour change”.
The free of charge training modules and patient-facing materials can be accessed at haleonhealthpartner.com/en-gb/centre-for-human-sciences.