Pain is a universal symptom and yet pharmacists—as the most accessible healthcare providers—can play a vital role in helping people address their pain by assisting them in safe and effective pain management, writes Leanne Philpott.
IN ADDITION to its core dispensing role, the pharmacy can offer competencies and services relevant to those people living with acute and chronic pain such as HMRs, enhanced self-care support to protect against overuse or misuse of analgesics and NSAIDs, assessment tools to identify persistent pain risks—while also facilitating multidisciplinary support through referrals and the provision of information.
Broken Hill community pharmacist Alex Page, winner of the 2013 PSA Award for QUM in Pain Management, says, “The biggest hurdle to improving pain management is changing patients’ understanding of pain and how it is best managed. Unfortunately many people believe there’s a ‘silver bullet’ medication that will ‘kill’ their pain.”
Page tells the AJP that he loathes the term ‘pain killer’ and explains that through HMRs, Medschecks and patient counseling, he tries to help patients conceptualise their pain better so they can understand that medication is a very small aspect of pain management.
“I promote active management strategies to patients as a way to optimise how well their medicines can work. I also endeavour to ensure the patient is taking appropriate medications for their type of pain and I regularly liaise with GPs through HMRs and Medschecks to discuss medication options for my patients,” he says.
Through HMRs Page has been successful in identifying and addressing ineffective pain coping mechanisms and the link between chronic pain and depression.
He says, “HMRs present an unparalleled opportunity for a health professional to assess the coping mechanisms of a patient with chronic pain and view how their living environment and family impact their pain management.
“In health we are often forced to rely on information given to us by the patient, which may not always be accurate so it is invaluable to have an opportunity to assess a patient’s coping strategies in an objective and accurate fashion.
“Chronic pain and depression have a very strong correlation, which is due to multiple factors and many of these can be observed and assessed during the course of a HMR. You can also assess a person’s level of functioning during a HMR, which is a far better indicator of disability than pain intensity. It also has a stronger correlation to depression than pain intensity,” says Page.
Olly Zekry, clinical consultant pharmacist and winner of the PSA QUM in Pain Management Award 2014, explains, “One of my patients, Jackie, was a 58-year-old medical receptionist with a six-year history of lower back pain and a three-year history of type 2 diabetes. I visited her at home for an HMR.
“Apart from the fact the house was very messy and the kitchen was a little smelly, an indicator that she may be having difficulty coping, I noticed she winced when sitting down but she didn’t complain. I asked if she was okay and she replied, “My back is still bad”. I questioned further and she told me that she hadn’t been walking regularly for the past two months due to the problems with her back.
“In terms of pain history, her average VAS score was 6/10 and her worst VAS score 7/10. The pain was in the lumbar spine and at its worst radiated in the thigh region. Pain was reduced with bed rest. Her dose of paracetamol/codeine had been at the prescribed maximum (1000/60mg QID) for the past two months with no relief.
“When I interviewed Jackie I realised she had two potential red flag indicators; first she was aged over 50 and second her condition hadn’t improved after one month. However, she has no history of cancer and her back pain was first reported five years ago at the age of 50 years. Her GP had conducted an x-ray three months prior, which excluded any red flags.
“In Jackie’s case, her largest issues were her ability to do things—general activity, work and walking. As conservative analgesic therapy hadn’t enabled Jackie to implement active self-management strategies effectively, the decision was to consider the use of stronger analgesics.
“Jackie’s suitability for an opioid trial was assessed using the Opioid Risk Tool (ORT). She scored 2 points due to her sister’s past use of marijuana. Her score placed her in the low-risk category of developing aberrant drug-related behaviours so I recommended the following to the GP as part of her pain management plan:
- Cease paracetamol/codeine
- Start patient on buprenorphine patch 5mcg/ph
- Continue with heat packs
- Encourage Jackie to increase her level of physical activity and the frequency of walking from every second day to daily
- Encourage patient to lose weight.”
“Jackie’s opioid use was monitored by the GP using the ‘6 As’ opioid therapy monitoring tool. After two weeks her VAS score went down to 5/10 so the GP increased her buprenorphine dose from 5mcg p/h to 10mcg /ph.
“At week six I reviewed her progress. She achieved all of her goals successively, except for her goal regarding weight loss.
“As the period of the buprenorphine trial had ended a decision needed to be made regarding ongoing use of this therapy. The combination of buprenorphine and the implementation of self-management strategies had helped to reduce pain levels and enabled her to increase her level of activity, so she agreed to continue the use of buprenorphine patches. I updated the treatment goals in her records. Her progress will be monitored by monthly reviews and her GP will discuss stopping opioid therapy once she has achieved her goals and her physical condition has improved.”
Zekry says, “Chronic pain has a broad impact on an individual’s life as well as those closest to them. Chronic pain can adversely affect the ability to function, their emotional wellbeing as well as having social and financial consequences.
Zekry says best practice management of chronic pain requires a biopsychosocial approach. “This means understand what is happening to the body, what is happening to the person and what is happening in the person’s world?
Zekry explains how a biopsychosocial or multidimensional approach involves the following steps:
- Assess all contributing pain diagnoses. Take a detailed pain history and conduct a physical examination. What is the location of the pain (anatomical)? What is the pain mechanism, for example, neuropathic or inflammatory? Rule out red flags such as cancer, infection or fracture.
- Consider all medical comorbidities that could influence the presentation of pain, such as diabetes, dementia or its management, renal impairment and sleep disturbance.
- Assess psychological contributors, documenting psychological responses to pain such as catastrophising, coping style (active or passive) and low self-efficacy. Identify any yellow flags (for example, attitudes and beliefs about pain, behaviours, emotions) that may impede the rehabilitation process. Identify the presence of major depression and general anxiety disorder.
- Socioeconomic assessment requires the documentation of the socioeconomic consequences of pain, such as impact on employment and finances, social isolation or levels of support. Consider extrinsic factors that will affect pain, such as physically strenuous employment or adaptable work environment.
- Conduct a risk assessment for medication misuse. Assess the risk of developing problematic behaviours with medications such as opioid analgesics.
- Assess the impact of pain on the ability to function and perform normal tasks.
“In instances where there is no cure for the pain you can still apply a biopsychosocial approach to pain management. The aim then becomes to shift the patient’s focus from having a pain-centred life to improving function despite persisting pain,” says Zekry.
Paradigm shifts that will help enable the application of a biopsychosocial approach to the management of patients with chronic pain include:
- seeking a cure to optimising rehabilitation and function despite the pain (includes acceptance of ongoing pain)
- pain (and reducing pain severity) to improving function
- analgesics as the primary focus of therapy to multimodal therapy (i.e. using a combination of physical and cognitive therapies in addition to medications to manage the patient’s chronic pain)
- treating the patient (passive) to enabling the patient to take an active self-management role.
Elizabeth Carrigan, CEO of Australian Pain Management Association Inc. (APMA), says that expanding the role of pharmacist in pain management from dispensing to educating patients, for example about side effects and also the unintended consequences of some drugs, is important.
“20% of all Australians are affected by chronic pain. Many patients are prescribed medication and a large proportion of patients take opioids before attending the pain clinic. This puts some responsibility onto pharmacists to educate and inform about the safe use of these medications, whether prescribed or over-the-counter (OTC) given their potential for tolerance, dependence and in some cases, for addiction. Given this last possibility, opioid drugs are strong candidates for abuse. In addition, deaths have been attributed to opioid prescription overdose by the Victorian Coroner’s Office.
“Unless pharmacists can ‘value add’ to the dispensing of medicines, not only is it a waste of expensive clinical resources, community pharmacy risks being overtaken by online stores and I wouldn’t like to see that future scenario,” says Carrigan.
She adds, “Some of the ways that pharmacists can and do assist are by checking that patients are on an optimal dose of analgesics, monitoring repeat prescriptions as well as patients’ self-medication with OTC analgesics in combination with prescribed analgesics. This provides necessary checks and balances in the medications system resulting in less adverse events.
“Pharmacists should be examining a patient’s medicines and discussing treatment with their doctor with the view to optimising medicines and minimising potential problems. Pharmacy reviews are important for the successful management of chronic pain,” she says.
Carrigan notes that medications have only limited scope in treating chronic pain. “Realistically, there isn’t one drug that can take all the pain away. Verbal advice—helping patients towards acceptance of ‘tolerable pain’—will improve wellbeing. There is not much efficacy for opioid medication improving outcomes long term, but they are widely employed for the treatment of chronic pain, and pharmacists, being experts in the field, have a role in chronic pain management by ensuring the safe and effective use of these medicines.”
Having been a community pharmacist for six years, Page says he is frequently reminded about the extensive and widespread use of codeine. “While there are many patients who use codeine-containing analgesics appropriately, there still appears to be a large number who do not,” he says.
Page explains how he took action to address this behaviour. “Limiting the supply of codeine to a maximum of five days was a good initial step but we found that it was still hard to gauge how often someone used codeine-containing analgesics as they would obtain it from multiple pharmacies. To address this all the community pharmacies in Broken Hill decided to record the sale of codeine-containing analgesics through the Project Stop database. In the three years we have been doing this we have dramatically reduced the inappropriate use of codeine-containing analgesics and, perhaps most importantly, it has allowed us a counseling opportunity as we can talk to those who are regular users of codeine-containing analgesics.”
Health literacy and advice
In 2014 APMA produced Getting back on track, an accessible consumer low back pain management brochure, which Carrigan says could be used to back-up pharmacist advice about medication use and safety, fear avoidance and staying physically active with lower back pain.
She says, “The brochure, coupled with pharmacist verbal counselling to reinforce key messages, could focus on making patients more active participants in their own pain care. Having pharmacists make use of the information means current, evidence-based and easy-to-understand information is immediately accessible to consumers at the community level.
“Chronic low back pain is the leading cause of consumers leaving the workplace because of poor health in Australia. Yet pharmacists have the capability to bring together more realistic beliefs and behaviours to improve patient outcomes with chronic pain. Simple and cost effective partnerships with community organizations can help the millions with lower back pain to remain in the workforce or keep their lifestyle going to improve their back health,” says Carrigan.
“Australian research suggests that the use of active self-management strategies amongst patients with chronic pain can be improved,” says Zekry.
“A telephone survey of people with chronic pain investigated the use of active and passive management strategies to manage chronic pain. This research identified that passive strategies were more common than active strategies. The most commonly used therapies were, medication use (47%), rest (32%), exercise (26%) and heat or cold packs (23%).
“It also investigated the associations between treatment modality and pain related disability and found that people who employed active management strategies only were less likely to have pain-related disability (adjusted odds ratio 0.2),” explains Zekry.
“The increasing prevalence of chronic pain in our ageing population is a major issue that poses larger burdens on the patient population. Some impacts are: decreased physical activity, withdrawal and isolation, over use or inappropriate use of pharmacy services and products. Chronic pain management is complex and requires a changing focus from pharmacists to become part of the multidisciplinary team,” says Carrigan.
Page says, “HMR-accredited pharmacists play a huge role in referral and instigating multidisciplinary support for customers with chronic pain. Pharmacists are still somewhat of an isolated branch on the primary healthcare tree but this has steadily improved as Universities and professional bodies continue to push the multidisciplinary care model.
“Pharmacists would connect with more patients in a given day than any other health profession, so we are a crucial cog in identifying which customers could benefit from support from another health care professional. The referral part is trickier as community pharmacists can seldom direct refer to another health professional, especially those who are subsidised by Medicare. I see this as a priority to improving the management of not only chronic pain, but many other chronic illnesses,” says Page.
e-health—potential for better pain services
Carrigan says that given the shortage of pain medication specialists, e-Health has the potential to increase the capacity.
He explains, “e-Health enables consultations between specialists and GPs to occur via video link. As well, GPs are able to book meetings with the specialists to get advice on a complex medical case.
“Pharmacists could be involved in these meetings. Some pain clinics, like the Gold Coast Persistent Pain Service, have a pharmacist involved. Private specialists could be more involved and local GPs could also involve the local pharmacist
“Community pharmacists need to be able to access the electronic health systems that are being rolled out by States, such as the Enterprise Patient Administration System (EPAS) in SA. When it is fully implemented it could make a marvellous difference to healthcare, particularly for the “frequent flyers” in the public system. EPAS has the potential for hospital-based scripts to be filled by community pharmacists—producing a streamlined hospital-based prescribing and community pharmacy dispensing system.
“Potentially, if community pharmacies are integrated into eHealth records systems, medication safety could improve as could optimal use of medicines due to better continuity of patient information.
“Beyond the pharmacy itself, scope exists for pharmacists to be located in general practices and community health centres, giving people better access to their services—particularly large primary health care practices, which are already providing consumer management and prevention education,” Carrigan says.