Targeting pain

Despite the downturn in the analgesics category, pharmacy’s trusted advice and proactive approach might just be the key to driving positive future growth

According to Nielsen data, in the last year pharmacy has experienced ‘significant declines in the analgesics category’. This has come off the back of increasing concerns in the media over the safe use of pain relief medication for children, discount pharmacies driving down prices—and then there’s the imminent rescheduling of codeine-containing products.

We’re already seeing the impact the TGA’s decision to switch codeine to prescription-only from February 1, 2018 is making on the analgesics category, and it’s likely that these affects will be felt for some time.

Nicole Hooley, retail projects manager at Instigo, tells the AJP, Last year we incorporated MedsASSIST into our pharmacy stores, which did result in a decline in codeine sales but also in the overall analgesics category, incorporating S3 pharmacist-only and OTC medicine.

“We’re now looking at a more holistic approach for our customers and how we start positioning our conversations to initiate the education and effectively manage the lead up to the codeine-related changes in early February.”

Emily Cox, senior research analyst at Euromonitor International and author of the Analgesics in Australia report (September 2016), says the performance of analgesics over the forecast period is very dependent on the changes to codeine products with consumers either turning to their doctor for a prescription or switching to alternative products such as paracetamol and ibuprofen combinations.

Hooley says the key for pharmacy is to be proactive and start initiating conversations now.

She says, “We know from our pharmacy group catalogue that a high number of our codeine users are addicted to the codeine and, according to AFT Pharmaceuticals surveys, these customers have said they will continue to use codeine up until the deadline and then they’ll go to the doctor for an alternative.

“However, there are still many customers that will switch to an alternative if it treats their pain, but they just need the advice and an understanding of why they need to change.

“Across our pharmacy group we’re focusing on the trust and advice-driven conversations. This is the basis for educating and swapping the customer from a codeine-based solution to an OTC analgesic.

“However, the conversation with those customers that are using codeine because they’ve formed an addiction is going to be much harder than the conversation with people using it for acute pain.

“The feedback from our members is that this is going to be the biggest challenge and the general feeling across the industry is that the codeine users will continue to buy it right up until the change, so pharmacists need to stay strong and continue to talk about the options available.”

Hooley says pharmacists need to be prepared to have the same conversations time and time again over the next few months. “Even if the customer doesn’t take action immediately, it will help lessen the hysteria when the TGA’s ruling comes into effect.

“The industry thinks that around 40% of customers may go onto prescription, which puts a lot of pressure on the doctors and surgeries but also it’s important for pharmacists and pharmacy owners to understand what their local doctors’ strategy is come Feb 1.

“Are they going to be accepting and taking those prescriptions or will they be refusing to dispense codeine prescriptions to non-customers?

“It’s a big shift and there’s likely to be conflict so any planning and preparation that can be done prior will be helpful. Pharmacists need to be proactive in talking to allied health professionals about the impending treatment plan for customers.”

Continuing education

Ally Sammassimo, business development manager, Guild Learning and Development, The Pharmacy Guild of Australia, says that in spite of the current changes, pain—whether acute or chronic—is the most common reason people seek medical help from pharmacies and GPs. As such, it will continue to provide an opportunity for pharmacists to improve both patient outcomes and pharmacy profitability.

Sammassimo says that in the lead up to the up-scheduling of codeine-containing analgesics pharmacists need to ensure their staff are aware of the evidence for non-codeine containing analgesics, able to determine patient suitability and know when referral to the patient’s doctor is required.

“Pharmacists play a valuable role in educating the patient about effective pain management options and providing support to help them self-manage. Pharmacists also have a duty of care in determining a genuine therapeutic need when a patient requests a pharmacist-only analgesic.”

One of the leading players in the analgesics market, mainly due to its Nurofen Plus brand, is Reckitt Benckiser. GIven that Nurofen Plus will be impacted by the proposed codeine-related changes, the company has launched pharmacist-only adult combination analgesic Nuromol.

“In the lead up to the codeine reschedule we are seeing the biggest opportunity for growth in our ibuprofen-paracetamol combination product Nuromol. As such, this product will be a key focus for the business in the next 12 months,” a spokesperson for Reckitt Benckiser (RB) told the AJP.

They went on to say, “Looking at the analgesics industry as a whole, everyday pain relief is the largest category. In the lead up to the codeine reschedule, pharmacists must continue to play a crucial role in educating consumers on the multiple pain relief options available over the counter, including products that can be taken as an alternative to codeine containing medicines.  

A spokesperson for RB said that the company had recently reviewed its existing educational initiatives and will be replacing its Health Hub with a series of partnerships with the Pharmacy Guild of Australia (PGA) that will offer additional practical benefits for pharmacists and contribute towards their professional development.

Sammassimo notes that it’s important for pharmacists and their staff to be aware that different brands on the market can contain the same active ingredients but different dosing instructions and different maximum daily doses.

She explains, “Maxigesic contains a combination of paracetamol (500mg) and ibuprofen (150mg) in a single tablet. The recommended dose of Maxigesic is 1-2 tablets every six hours as required, to a maximum of eight tablets in 24 hours. This translates to a maximum total dose of 4000mg of paracetamol and 1200mg of ibuprofen per day.

“However, Nuromol contains paracetamol (500mg) and ibuprofen (200mg) in a single tablet. The recommended dose for people aged 12-65 years is one tablet every eight hours as necessary to a maximum of three tablets per 24 hours. This is a total of 1500mg paracetamol and 600mg ibuprofen per day.

“Since mid-2016 the NSW Poisons Information centre has witnessed a spike in calls from consumers worried they may have accidentally overdosed on a paracetamol and ibuprofen combination analgesic. This highlights the important of pharmacist counselling with patients that purchase these medications to ensure appropriate use.

“Additionally, as these medicines are Schedule 2 in pack sizes less than 12, it’s important that patients are advised to read the instructions on all medicines,” says Sammassimo.

She adds that the benefit of a combination analgesic is that they may provide greater analgesic effect than a single ingredient alone. “Approximately 50% of people do not achieve the pain relief they require from a single agent analgesic and may require a combination of active ingredients to target their specific type of pain.”

Setting pharmacy apart

Mark Nicholson, partner at Pitcher Partners, says, “Whether it is a chronic or acute condition, [the S3 category] offers the opportunity to problem solve or allows for a level of interaction with the customer that in turn can generate long-lasting goodwill.

“Most customers will act upon professional recommendations and appreciate the input from a pharmacist, so each time this interaction is not optimised it constitutes a lost opportunity. Specifically, pharmacies need systems and processes in place (and often in busy pharmacies a pharmacist dedicated to the Schedules section) that maximize these brand-building transactions and are focused on outcomes for the patient rather than the price of a product.”

When it comes to pricing, Cox says that discounting has hindered the analgesics market but this is likely to be counteracted by our ageing population and sales of analgesics to those aged 65 and above.

Nicholson adds that in respect of competition from discount retailers, it’s imperative that pharmacy owners recognise that a convenient location is often the most important component of the value equation.

He says, “While price is not unimportant (and providing a pharmacy is not uncompetitive) it is difficult for discounters to unhinge customers from their competitors convenience locations, for example being close to a supermarket, work, doctors, the school.

“As such, price is unlikely to be the main cause of customer loss or indeed a driver of growth. Rather a solutions-based approach that leverages the skills, knowledge and advice of a pharmacist will provide both the value-add opportunities and differentiation to other retailers that underpins the trusted brand of pharmacy and supports the higher margins required to operate a services-focused pharmacy in a convenience location.”

Sammassimo says, “Pharmacists are in the unique position to be able to take a thorough patient history, assess the appropriateness of the patient’s request and determine the suitability of medication supply or whether referral is necessary.”

She says the trusted advice and skill set of the pharmacist sets the business apart from other retailers. “Pharmacists should always provide advice for the patient on the appropriate use of the medication, but also on additional pain management measures including non-drug therapies.” (see counselling box)

“Discussing pain management with patients also presents an opportunity to provide them with patient resources such as those from Pain Australia, which offer information to assist patients in self-managing chronic pain.”

An holistic approach to pain

Cox says that alongside the rescheduling of codeine products, the health and wellness trend may also impact sales of analgesics as Australians become more concerned about the ingredients in the products they consume.

“[Consumers] are expected to shift their focus towards more natural or herbal alternatives to pain relief, as well as seek to improve their overall health and wellbeing, thus adversely impacting sales.”

Hooley is already seeing evidence of this. She says, “Natural therapies, such as vitamins and nutrition, have seen a really good increase in quite a competitive market.

“We’ve seen that fish oil, glucosamine and krill oil—those products directly correlated to pain and in particular arthritic pain—have witnessed an increase in sales.

“In line with this we’ve put a strategy in place for our pain category that incorporates solution merchandising. This will see natural therapies, devices, creams and rubs positioned within that category. It will be overlaid with in-store training on how to sell solutions, how to manage the category and when to direct customers to the pharmacist.”

She says the training will also incorporate how to respond to customers who are asking about codeine.

“We need to advise customers that there are going to be changes to this type of pain management option and talk to them about how we can assist in this transitional phase to find the best alternative pain management for them. This may include recommending natural therapies as an addition to their current method of treatment.

“We’ll be looking at the whole solution, so instead of offering just an oral analgesic to help with pain, we can team this with a topical treatment such as an anti-inflammatory rub, hot or cold pack, as well as adding in natural therapies.

“It’s all about the features and benefits of the products so conversation with the customer needs to address this. We need to be teaming the solution with information. If the information isn’t there, people may pick up a product out of curiosity but if they haven’t shopped the natural health area before they’re less likely to understand why they should purchase the product.

“The only way for success in any category is for people to have the training and knowledge. You can never get enough training; even for the most experienced shop assistant and people who have been working in pharmacy for many years there’s always more training they can do and more evidence. The more knowledge you have the more confident you’ll be in recommending the right solution for the customer,” says Hooley.

Nicholson says, “Most Australians use some form of pain relief on an annual basis. As such it is likely that pain relief is the pharmacy category that provides for the broadest possible interaction with broadest range of customers.

“Pain relief quite simply is the cornerstone category for a pharmacy to build from and achieve customer, sales and reputational growth.”     

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