“Specialist services cannot see everyone with chronic pain. The problem is just too large but many pharmacists could deliver similar services in the community,” says Helen Liddell, an advanced clinical pharmacist for a community pain service run by Connect Health.
“Rates of opioid prescribing seem to be levelling off or declining in some areas over recent years,” remarks Liddell, who is also a committee member of the UKCPA Pain Management Group, “but we are not doing enough. Opioid prescribing remains a massive problem”.
A study that analysed Scottish prescribing data between quarter one 2005 and quarter two 2020 offers grounds for cautious optimism. In 2013, the Scottish Intercollegiate Guideline Network (SIGN) published guidelines on chronic pain management. By the end of the study, opioid prescribing had declined by 20.7 per cent. Less use of weak opioids accounted for most of the fall. Prescribing of strong opioids rose, but more slowly than before the guidelines. Gabapentinoid use also increased.1
“While there appears to be some reductions in opioid prescribing, overall use remains high,” says Emma Davies, advanced pharmacist practitioner in pain management at Cwm Taf Morgannwg University Health Board, who spoke to Pharmacy Magazine as a representative of the British Pain Society.
“Education and guidelines increased health professionals’ awareness of the long-term harms of analgesics. Public education, however, tends to focus on dependence and misuse rather than the long-term health concerns, such as depression, anxiety, falls and fractures, and reduced endocrine and immune function.
“Most importantly, patient education does not really cover the often poor efficacy of analgesics, including opioids, at improving pain and related outcomes, especially in long-term conditions – but non-pharmacological support is not universally available to those who may benefit.”
Davies points out that opioids are prescribed within all sectors and all specialities. “Many initiatives focus on primary care, so specialists who are, perhaps, less well versed in the risks often start or recommend opioids,” she says. “In short, the expectation remains that ‘medicine’ has an answer to pain and in the absence of timely, acceptable alternatives, analgesics remain the most likely intervention.”
“We live in a consumer society,” adds Liddell. “We expect drugs to fix our problems but that isn’t the case in most people whose life has been disturbed for years by chronic pain. The best analogy is with antibiotic prescribing. Most people now know they won’t be treated with antibiotics for flu. Similarly, we need to change the public’s perceptions about opiates for persistent pain. We need to reframe chronic pain and move away from a simplistic focus on opioid overuse.”
As part of a specialist service, Liddell often manages the worse cases of persistent pain. “By the time patients get to me, they’ve often tried everything and have been bounced between services,” she says. “I’ve had patients burst into tears because they feel that someone now believes them and is sympathetic.”
Perhaps that is one reason why patients are open-minded about her suggestions. “They’ll try anything to get better [and] to have a normal life,” she says.
Pharmacists and other healthcare professionals should be “empathic and sympathetic” when discussing management options, says Liddell, and this includes being careful about language. “Healthcare professionals should avoid the term ‘addiction’ when discussing opioids. ‘Depend’ is more accurate. Similarly, ‘persistent pain’ is better than ‘chronic’. Addiction and chronic have, in my view, negative connotations. We need to be careful about not being judgemental and so we need to be careful about terminology.”
Different response rates
Pharmacy teams should also bear in mind that patients vary widely in their response to opioids. “Some people on low doses experience marked side-effects,” says Liddell. “Other people don’t seem to have developed side-effects despite taking high-dose opioids.”
Genetic factors may be partly responsible. In animal models, genes explain about 30-76 per cent of the variation in opioid response. For example, cytochrome P450 2D6 converts prodrug opioids (e.g. codeine) to their active metabolites. Genetically determined variations in CYP2D6 activity may predict poor pain control and adverse reactions with codeine.2
Livewellwithpain.co.uk (see later) offers several resources to help healthcare professionals individualise discussions with patients, such as the ‘Opioid Lottery’ and ‘Ask 6 Questions for Gabapentinoids’.
“These are useful tools to start conversations about medicines,” says Emma Davies. “They encourage discussions about problems that patients do not realise are probably related to their medicines, rather than just bad luck or yet another condition. Pharmacists should ask people using analgesics: ‘What do these medicines allow you to do more easily?’ or ‘What things do you find difficult to do?’.
“The answers can be a good starting point to understand their issues and can be reflected back in the context of the problems we know analgesics, such as opioids, can cause. These interactions help people to learn about pain
and how to live with it more effectively.”
“We need to change the public’s perceptions about opiates for persistent pain”
Patient and professional education
Helen Liddell, who is involved in the Flippin’ Pain website, stresses that patient education is crucial. “We understand chronic pain better than ever before. If we explain the science of pain to patients and offer non-pharmacological alternatives, we will be able to manage pain better and minimise the use of drugs,” she comments. The Flippin’ Pain website provides resources and materials to support patients to better manage persistent pain.
“People are likely to consider pain as a symptom of an underlying condition rather than as a condition in its own right,” Emma Davies says. “By the time many people are given information about pain, they have lived with it and sought answers for a considerable time. At that point, patients can feel like they are being fobbed off by a professional who can’t think what to do, rather than it being an explanation in and of itself.
“The best thing we can do is to find out what matters to the person living with pain. This can take time and requires trust on both sides. Finding out what people care about, what they miss, what they’d like to spend their time doing
is the best way to build motivation to change.”
For example, pharmacists could stress that acute pain arises from tissue damage. Chronic pain, in contrast, arises from changes to the nervous system. Partly because of this, Liddell stresses that coming off opiates does not usually happen overnight.
“Reducing opioid use is a bit like smoking cessation: you have to wait until patients are ready. And, like smoking cessation, reducing opioid use takes time,” Liddell says. “Too many people are taken off opioids too quickly. Reducing or stopping opioids means retraining the nervous system. The pace needs to be controlled and, if necessary, part of a negotiated agreement. Coming off opioids can be a bit of a bumpy road.”
Package of measures
Any plan to cut down opiate use should include the management of flares, which are almost inevitable. “It is important to have a package of measures to address the dynamic nature of chronic pain,” says Liddell.
“It is wrong to suggest that medicines are bad or should not be used or offered to people with pain,” agrees Emma Davies, “but people prescribed analgesics should be regularly reviewed and when analgesics are not helping or causing harm, they should be reduced and, ideally, stopped. We should encourage patients to view analgesics as one part of the pain management jigsaw, rather than the whole picture.”
Both stress the importance of pharmacist education. Liddell is clinical director at MORPh Primary Care Network, which provides training about pain management for pharmacy teams. Davies is a co-founder of livewellwithpain.co.uk.
“We felt there was a gap in terms of resources and training for professionals, especially in primary care. The website is free, although we encourage registration, which helps direct users to the most appropriate resources,” Davies explains. “In the five years since we started livewellwithpain.co.uk we have expanded the range of resources provided, including the ‘10 Footsteps’ programme.”
Developed as part of a research project with Durham University, the initiative improves outcomes and reduces the use of, and reliance on, analgesics. “There is a section on medicines and Footstep 9 considers the place of medicines in pain management,” Davies says. The 10 Footsteps is available in versions for patients, professionals and carers, which should, ideally, be used together.
“The practitioner’s version goes through the footsteps with advice on how to encourage the patient to engage with the ideas and work through the resources, so that they get the best outcomes they can,” she says.
“Reducing opioid use is a bit like smoking cessation: you have to wait until patients are ready”
Sleep deprivation, stress and a lack of social contact can exacerbate chronic pain and are, potentially, modifiable. For example, poor quality and insufficient sleep increases the risk of chronic pain, hyperalgesia (increased sensitivity to painful stimuli) and pain symptoms (e.g. myalgia or headache). Chronic pain can also disturb sleep.
A cycle can become established, which often gradually deteriorates3, but as Anaesthesia notes: “Chronic pain can be associated with significant disruption in brain activity during sleep. Furthermore, this disruption is not improved, and may even be exacerbated, in patients taking opioid medication”.4
The public’s generally poor understanding of pain and its management means that patients may not easily accept non-medical interventions, says Davies. “Often non-medical interventions can appear hard work and are likely to take time to relieve pain and improve outcomes. In contrast, medicines remain relatively easy to get and are still considered likely to rapidly improve symptoms.
“Pharmacists should ask the individual what they want to know about pain and how that may relate to their situation. We may want, for example, to break the myth that osteoarthritis and pain are the same thing. But if addressing misconceptions takes time away from helping the person to move on and change what they ‘do’ about their pain, then it may not be the best use of time.”
“There is good evidence that getting and remaining active, moving more, losing weight, eating as well as you can, undertaking relaxation and mindfulness, and making time for hobbies can all improve quality of life, wellbeing and general health and, in turn, contribute to reductions in pain intensity and interference,” Davies adds. “However, we need to be careful about suggesting that anything works in isolation.
“For many years self-management strategies were introduced when other ‘medical’ interventions had failed or been exhausted, so we need to be much better at introducing supported self-management at the first opportunity. Self-management strategies can benefit all pain types and should not be offered only when pain persists.”
Some risk factors for chronic pain are more intractable. For example, childhood physical, sexual and psychological abuse increase the risk that the person will develop chronic widespread pain as adults between two- and three-fold.5 Indeed, childhood abuse can increase the risk that adults will develop several conditions that cause persistent pain, including fibromyalgia, irritable bowel syndrome and chronic pelvic pain.5
“There is a very strong link between adverse childhood experiences and chronic pain,” Helen Liddell remarks. “Tackling these issues takes long-term counselling and support, which is not always available.”
Pharmacists should refer patients they suspect of experiencing depression and anxiety to their GP. People living in chronic pain are more likely to experience clinically significant mood or anxiety symptoms. Depression is, for instance, three or four times more common among people with chronic pain than in the general population.6
Of course, living with pain can trigger anxiety and depression – but depression and distress can also increase the likelihood of transitioning between acute and chronic pain.5 Opiates may be less effective in people with negative affect (mood and anxiety symptoms).
A study of people with back pain found that analgesia produced by oral opioids in people with high levels of negative affect was about half that in people with low negative affect.5 “Teasing out the relationships between depression and anxiety and chronic pain is often very difficult,” Liddell says.
“We now need to reframe our thinking and make sure ‘every contact counts’ with a patient living with persistent pain,” Liddell concludes. “Patients and healthcare professionals need to appreciate that reducing or stopping opioids means retraining the nervous system.
“You can’t reduce or stop opioids overnight and there will probably be setbacks but, with support from their pharmacist, patients can move forward.”
- Implementation Science 2022; 17:77
- The Pharmacogenomics Journal 2022; 22:117-123
- Neuropsychopharmacology 2020; 45:205-216
- Anaesthesia 2016; 71:1296-1307