Pain management and opioid misuse

Despite regulatory changes to codeine, pharmacists continue to play a vital role in the safe and appropriate use of analgesics

As our knowledge of pain has progressed, we now recognise the complexity of the issue and the many challenges associated with finding an effective treatment.

Professor Gino Martini, chief scientist at the Royal Pharmaceutical Society, UK, explains that understanding the various types of pain is essential, as each one involves a different treatment regimen.

“Acute pain comes and goes relatively quickly and is often associated with an injury or inflammation. It is usually treated with a course of over-the-counter (OTC) analgesics. A 2015 Cochrane review found that ibuprofen or paracetamol combination is effective in the majority of patients with this type of pain.”

In a 2015 Cochrane Review, Moore et al looked at the OTC analgesics available in the UK, Australia, Canada and the USA and the evidence to support their efficacy for acute post-operative pain. According to the results, “Combinations of ibuprofen plus paracetamol had success rates of almost 70%, with dipyrone 500mg, fast-acting ibuprofen formulations 200mg and 400mg, ibuprofen 200mg plus caffeine 100mg, and diclofenac potassium 50mg having success rates above 50 per cent.”

Paracetamol and aspirin at various doses had success rates of 11% to 43%. The authors state this knowledge can be used in clinical practice to educate people on the fact simple drug combinations and fast acting formulations deliver good analgesia in many people with acute pain, and at relatively low doses.

“Chronic pain, on the other hand, lasts longer than three months or persists over a three-month period. As it’s a long-term condition, patients need to be treated individually; there’s no one-size-fits-all approach. What practitioners need to be mindful of is if people use an analgesic with an opioid there’s potential for addiction issues.

“Chronic primary pain is a relatively new concept and not really evidenced. It is where pain is long term and lasts longer than three months, but there’s no perceivable cause. In this case non-pharmacological treatments are recommended. What is often prescribed is a form of exercise, psychological counselling or, in some cases, complementary therapy like acupuncture.”

Prof Martini says when it comes to treating pain, “it’s very clear that pharmacists could and should do more.”

Opioids: a hot topic

According to Pain Australia, in 2020 3.37 million Australians were living with chronic pain. What’s more, most people with chronic pain (68.3%) are of working age and report their pain significantly restricts their daily activities.

With regards to how people manage their pain, 63% were using opioid medications, despite evidence showing that for patients with non-cancer chronic pain opioids offer little benefit.

It comes as no surprise then that the misuse and overuse of opioids was the hot topic at the National Medicines Symposium, hosted by NPS MedicineWise at the end of last year.

NPS MedicineWise spokesperson and pharmacist Rawa Osman explains, “We know that over the past 20 years or so the trend in terms of opioid use has been increasing. It’s been rising steadily in the treatment of chronic pain; this is despite the fact the evidence base has changed and our understanding of the role of opioids has altered significantly.

“The information we now have on chronic non-cancer pain shows the limited role of opioids and the increased risk of harms. However, we are not really seeing a downward trend in prescribing or in opioid use. As a result there is a lot of long-term use of these medicines in the community and consequently we are seeing a lot of harms associated with this.

“Every day in Australia three people die from drug-induced deaths involving opioids, there are close to 150 hospitalisations and 14 emergency department admissions relating to opioid harm. This shows the significant impact opioids have on the community, on the individual, but also on the health system.

Indeed, part of the issue with regards to opioid use and misuse in the community is people’s lack of knowledge or misconstrued perceptions of the benefits of opioids for pain relief.

A lack of knowledge

Ms Osman tells the AJP, “We ran a survey between late 2019 and early 2020 with approximately 1000 consumers from the general population. We wanted to understand how much people knew about opioids.

From the results, we found that people were familiar with the term ‘opioids’ but they couldn’t identify the medicines within that class of drug. Even patients who had used opioids before weren’t able to accurately distinguish that the particular medicine they were taking was an opioid.

“Only 56% of the consumers we surveyed were able to identify morphine as an opioid. However, on the opposite side of the coin, about a third of consumers thought paracetamol and ibuprofen were opioids. So, identifying the medicines that fit within the group is a key gap for consumers.

“We also identified an overestimation of the benefits of the medicine or unrealistic expectations of the medicine. For example, there’s the idea that opioids can take the pain away completely, which we know is not true. However, this misconception was deeply embedded in a lot of the consumers we surveyed.

“In terms of the harms, some consumers were aware of the risk of opioid dependence, which is great as it’s one of the side effects. Yet only a third were aware that opioids can actually make the pain worse; so the concept of opioid-induced hyperalgesia isn’t widely known. Similarly, the link with hormonal imbalances as well as the association between opioids and depression isn’t well recognised either.”

In addition to a gap in knowledge about the risks of opioids, there is also a lack of general awareness of the non-pharmaceutical treatments for the management of pain. “It’s not just consumers, but also some healthcare professionals that are not up to speed on the non-pharmacological treatment options that are available, the evidence for their use, and how to get the patient ready to be an active participant in their treatment,” explains Ms Osman.

“Aside from being familiar with the other treatment modalities, it is important pharmacists know how to access these treatment options. Where can you refer the patient? What benefits will they receive?
“Harnessing the local pain network and working together as a team goes a long way in reinforcing key messages to the patient. By hearing unified messages time and time again, the patient is more likely to engage and more likely to participate in a tapering initiative, for example.”



The pharmacist’s role

“Pharmacists play a key role in engaging the patient in a discussion about their medicine. They really are the last line of contact before the opioid reaches the patient. As such, they are responsible for making sure the medication is safe and that it will meet the desired outcome for the patient,” says Ms Osman.

She explains that from the work she’s done as clinical lead for the NPS MedicineWise opioids program, she recognises that some pharmacists may perceive their role to be medicine supply only, without any scope to question the prescriber.

“It’s really important we re-affirm the pharmacist’s scope of practice, because rather than just supply the medicine we are responsible for patient-centred care and that involves patient safety.

“We must acknowledge that pharmacists are the medicine experts in this multidisciplinary team and we need to work collaboratively with prescribers, the patients and other healthcare professionals that care for the patients.”

Ms Osman says it’s really important that pharmacists stay up to date with the latest information and evidence, so that they’re prepared to have those conversations with patients and prescribers.

“Often patients confide in their pharmacist; they may tell you they haven’t been taking their medicine or they took more than the recommended dose because their pain was severe. Pharmacists, by nature, have a really good relationship with patients because they’re easily accessible. As such, they play a huge role in making sure patients’ concerns are addressed and that any medicine safety issues are identified and communicated appropriately.

“Of course, we must remember that patient consent is needed in order for us to speak to their GP. So, start the conversation with the patient; be open and frank. If the patient senses a genuine interest in their wellbeing and health outcomes they will be much more receptive to the messages you give and more than happy to have a conversation with you and allow you to relay any relevant information to their GP.

“From a pharmacy setting perspective, there may be time pressures on pharmacists and the layout of the store may not always be ideal to have conversations about a sensitive topic. So it’s important to choose the right time to have the conversation, when there are less people around or you have more time.

“Initially you can have a shorter conversation with the patient and then schedule an appropriate time later on, when the pharmacy is less busy. Rather than offloading all the information you know about opioids in a single discussion, plan to provide one or two key messages in each conversation.

“Discussing opioid misuse and harms is a challenging conversation to have with patients, but unless you try nothing will change. In the opioid space, in particular, we need everyone working together to shift that perception and to change the patient’s perception to get them on the same page as their doctor and pharmacist. Ultimately, we are all working towards the same goal, which is for better patient outcomes,” says Ms Osman.

See our April 2021 magazine for more of this feature

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