Helping to erase pain

Therapeutic management

Acute pain is generally straightforward to treat with analgesics, depending on the severity of the pain. Dylan Jones makes sure that patients take their analgesics responsibly. “I try to stick to prescribing just one pack [of analgesics] as a short-term measure,” he says. “This means they only use the analgesics for around two weeks and then have to go to their GP if they want more. 

“I may also recommend heat and cold therapy such as wheat bags, depending on the type of pain, or supports such as knee braces. Customers can buy these in the pharmacy, which they can’t from a GP surgery, which is a benefit of the pharmacy setting. I also direct customers straight to a physiotherapist if this is appropriate.”

Chronic pain can be more difficult to manage and can lead to low mood, anxiety, poor sleep and reduced movement if it persists. While some people benefit from analgesics, pain medication should be used alongside practical non-drug approaches, such as physical activity and mental health support. 

“We teach patients the difference between acute and chronic pain,” says Tracy Brown. “Patients may be frustrated as they have been referred for scans and X-rays and nothing has come up. It is important to explain that chronic pain is real and a condition in itself, and to educate them early on in the journey that medication isn’t the answer.” 

Long-term cancer-related pain is often managed with a stepwise approach to medication, using non-opioid medicines for mild pain up to strong opioids for severe pain. The problem with using this ‘ladder’ approach for non-cancer chronic pain is that this type of pain can be unpredictable and continue for many years. 

Non-medicine treatments may be more useful, such as electrical stimulating techniques (TENS machines), acupuncture, advice about activity and increasing physical fitness, and psychological treatments, such as cognitive behavioural therapy and mindfulness. 

“The first thing we do is reassure patients that we are going to help them control their pain and explain that a pain medicine isn’t working if they are still scoring 9 or 10 on the scale,” says Brown. “We help the patient self-manage their pain, sometimes with social prescribing and help for mental health, and try to help them get back to exercising. 

“We may introduce analgesic gels or a TENS machine but if someone is in a lot of pain over three months and the measures aren’t working, or they are coming in to buy stronger painkillers and have become reliant on them, it is important to refer them to their GP.”

Opioid prescribing

Opioids may help with acute pain, but there is little evidence that they can help long-term persistent pain and their sedative properties and addictive nature continue to cause concern. Guidelines from NICE state that chronic primary pain should not be treated with opioids, or even paracetamol. In Scotland, SIGN guidelines on the management of chronic pain state that opioids can be prescribed for chronic pain, in certain cases.

Despite these guidelines, prescribing opioids for the management of non-cancer pain is on the rise. According to a survey of over 4,000 adults aged 16 to 75 for BBC News in May 2022, a quarter of people in the UK are living with chronic pain – and nearly a quarter of these are being prescribed opioid painkillers in a bid to ease their pain. 

All drugs prescribed for pain should be subject to regular review to evaluate continued efficacy, says the Faculty for Pain Medicine (FPM). Tracy Brown recommends signposting patients to resources on opioids on the MHRA website and also to live well with pain (a not-for-profit educational website created by clinicians). 

“We need to help patients understand more about the long-term side-effects of the medication they are on and also how high their dose is,” she says. “Often, if patients are on full-dose tramadol and co-codamol, they are not aware of what this equates to when compared with morphine.”

Post-surgical use of opioids is thought to be an important source of problems, says the Faculty of Pain Medicine. On discharge, patients must be advised how to self-administer medicines safely, wean themselves off analgesics and dispose of unused medications. 

According to Dr Nicholas Levy, a consultant anaesthetist in West Suffolk, who wrote about opioid stewardship in the BMJ in January 2021, a recent UK study found that 14.6 per cent of people given opioids for the first time became long-term opioid users within a year. 

He wrote that, “appropriate prescribing of opioids should be a priority, focusing where possible on non-pharmacological strategies, including referral to wellbeing services, physiotherapy, exercise and weight loss programmes, as well as alternative therapies such as mind-body therapy and acupuncture.”

Many people with chronic pain stop doing everyday activities as they think this will make their pain worse, says Tracy Brown. “They become isolated and focused on their pain,” she says, “so encourage them to join activity groups to give them something else to focus on. 

“The Footsteps Festival run by Live Well With Pain is a collection of online events for chronic pain patients on anything from book reviews on pain management to online cookery and mindfulness courses. The Flippin Pain campaign (flippinpain.co.uk) has good learning resources for both patients and healthcare professionals.”