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Pharmacist CE Lesson
By Marsha Millonig, BS Pharmacy,
MBA, President/CEO Catalyst Enterprises, LLC
Author Disclosures: Marsha Millonig
and the DSN editorial and continuing
education staff do not have any actual or
potential conflicts of interest in relation to
this lesson.
Universal program number: 0401-0000-15-308-H01-P
Activity type: Knowledge-based
Initial release date: July 18, 2015
Planned expiration date: July 18, 2018
This program is worth 2 contact hours (0.2 CEUs).
Target Audience
Pharmacists in community-based practice.
Description
Pain, affecting 116 million adults in the United States, is the most
common reason that people seek care from a physician. In addition, numerous patients suffer from pain that can be managed by
over-the-counter medications and products. The pharmacist is in
a prime position to make recommendations and assist patients in
finding relief.
Program Goal
To provide pharmacists with updated information concerning pain
management recommendations.
Learning Objectives
Upon completion of this program, the pharmacist should be able to:
1.Differentiate the basic pain types, characteristics and classifications.
2.Review national population health strategies to ensure appropriate management of pain, while addressing potential abuse
and misuse concerns.
3.Compare and contrast safety considerations and product selection criteria for systemic nonprescription pain medications.
4.Describe local pain relief options, including hot/cold packs,
topical analgesics and counterirritants, as well as massage/
massagers and product selection consideration.
5.Develop a counseling strategy to guide patients and caregivers for both appropriate self-treatment of pain and when physician assistance is recommended.
To obtain credit: Complete the learning assessment and evaluation questions online at DrugStoreNewsCE.com. A minimum
test score of 70% is needed to obtain a statement of credit. Your
statement of credit will be available at CPE Monitor (NABP.net).
Your correct e-PID number must be included in your DSN CE
profile to ensure transmission of credit to CPE Monitor.
Questions: Contact the DSN customer service team at (800)
933-9666.
Drug Store News is accredited by the
Accreditation Council for Pharmacy Education as a provider
of continuing pharmacy education.
1 • july 2015
This lesson is supported by an educational grant from Wahl Home Products.
Updates in
therapeutic pain
management
strategies
Introduction
Pain is the most common reason
people seek care from a physician.1
Common chronic pain conditions
affect at least 116 million adults in
the United States at a cost of $560
to $635 billion annually in direct
medical treatment costs and lost
productivity.2 More than 76.5 million
Americans, or 26%, ages 20 years
and older report that they have had
a problem with pain of any sort that
persisted for more than 24 hours in
duration.2 Unrelieved pain can result
in longer hospital stays, increased
rehospitalization, outpatient visits
and decreased ability to function,
including concentration problems,
depression, lower energy levels and
sleep issues.3 Conditions associated
with chronic pain increase with age.
It is estimated that 60% of persons
aged 65 years of age and older experience chronic pain, and the number is
even higher among elderly nursing
home residents.2
These statistics are expected to
increase in the coming years as the
nearly 80 million baby boomers in
the United States are living longer.
While many are living more active
lives, they are at risk for developing
conditions that may be associated
with pain. When seeking pain
relief, a number of options exist for
patients beyond formal physicianprovided solutions. Many common
pain conditions are amenable to selftreatment with systemic and topical
over-the-counter analgesics and/or
such nonpharmacologic therapy as
heat and cold packs, massage and rest.
With an ever-growing number of overthe-counter options, the community
pharmacist is well positioned to
advise patients seeking pain relief.
With proper patient assessment skills,
the community pharmacist can guide
the patient in making appropriate
product selections, advise the patient
on the proper use of available overthe-counter options, assess whether
self-treatment is appropriate, and
offer recommendations for treatment
or referral.
Pain types
Pain is defined as the “unpleasant
sensory and emotional experience
associated with actual or potential
tissue damage, or described in terms
of such damage.”4 Pain is caused when
peripheral receptors carry energy
from noxious stimuli to the central
nervous system, or CNS, where
the brain interprets the transmitted
impulses as pain.1 Therefore, pain is a
perception, not a sensation.5
Pain often is characterized as
nociceptive — which can be somatic
or visceral — or neuropathic. Somatic
pain arises from the mechanical,
thermal or chemical stimulation
of nociceptors in the peripheral
nerve endings. Nociception is the
neural process that leads the brain
to recognize pain.4 Somatic pain
is constant, aching, squeezing or
throbbing and arises from bone, joint,
muscle, skin or connective tissue
(musculoskeletal pain). Visceral pain
may be deep, aching, cramping,
stabbing or gnawing and arises from
internal organs.6 Acute or chronic
inflammation may be involved in
nociceptive pain. It may be viewed
as promoting healing and preventing
tissue
damage.
Prostaglandins
released by damaged tissue make
the area more pain sensitive by
lowering the threshold of noxious
stimulation.5 Standard analgesics
and nonpharmacologic devices are
useful for this type of pain.
Neuropathic pain is caused by
damage or disease affecting the
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Pharmacist CE Lesson
central or peripheral somatosensory
system; it is pain caused by the nerve
itself. Patients often describe this pain as
burning, tingling or shooting. The primary
mechanisms
sustaining
neuropathic
pain are thought to be independent of an
ongoing tissue injury. Chronic neuropathic
pain arises from the peripheral or central
nervous system, involving mast cells,
neutrophils,
macrophages,
Schwann
cells and T cells.7 Examples are diabetic
neuropathy, viral infections, certain
hereditary conditions and chemotherapyinduced pain. Neuropathic pain responds
poorly to traditional analgesics.5
Pain also can be classified as acute or
chronic. In acute pain, the pain generally
is caused by a temporary problem and
may last a few days or a couple of weeks.1
Chronic pain often is defined as pain lasting
for more than three to six months, and
that causes distress and disability in some
cases. It recurs, is continuously present and
usually is a result of chronic diseases.8
Approaches to managing pain
Pain management treatments will vary by
the pain’s cause and characteristics and may
include the use of surgery; manipulative
therapies such as chiropractic; stimulation
therapies such as electric stimulation and
massage, and prescription and/or overthe-counter analgesics, both systemic
and topical. Pain treatment may require
combination therapy with a number of
options to be effective.
One survey of Americans’ perceptions
of how pain sufferers and the medical
community deal with the problems of
chronic pain showed that chronic pain
sufferers make major life adjustments in
addition to seeking medical care, including
taking disability leave from work (20%),
changing jobs altogether (17%), getting
help with activities of daily living (13%),
and moving to a home that is easier to
manage (13%). Most of pain sufferers (63%)
have seen their family physician for help,
while 25% have visited a chiropractor.
Over one-third has consulted more than
one practitioner in the medical community.
The study found treatments for pain have
yielded mixed results.9
Appropriate pain management continues
to receive national attention. In April 2015,
the Interagency Pain Research Coordinating
Committee (IPRCC) of the National
Institute
of
Neurological
Disorders
and Stroke (NINDS), was charged by
the Office of the Assistant Secretary
for Health to create a comprehensive
population health level-strategy for pain
prevention, management, research and
treatment.10 IPRCC has released a draft
report, entitled “National Pain Strategy: A
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Comprehensive Population Health-Level
Strategy for Pain,” which was created in
response to the Institute of Medicine’s
(IOM) 2011 report from the Committee
on Advancing Pain Research, Care, and
Education, “Relieving pain in America:
A Blueprint for Transforming Prevention,
Care, Education and Research.”2 The IOM
report called for a cultural transformation
in pain prevention, care, education and
research and recommended development
of “a comprehensive population healthlevel strategy” to address these issues. The
National Pain Strategy draft will be finalized
in 2015 after a public comment period.
At the same time that there is work
being done on a national pain strategy,
there is increasing concern in the United
States over the growing use and potential
abuse of extended-release and long-acting
opioid analgesics and other prescription
pain products. In its most recent report,
the Office of National Drug Control Policy
outlines an approach to drug policy built
on research demonstrating that addiction
is a brain disease that can be prevented,
treated, and from which people can recover.
The 2014 report provides an evidencebased plan for real drug policy reform, from
effective prevention, early intervention,
treatment, recovery support, criminal
justice, law enforcement, and international
cooperation.11 Additionally since July
2012, the Food and Drug Administration
has implemented a Risk Evaluation and
Mitigation Strategies, or REMS, that require
all manufacturers of long-acting opioids
and extended-release opioids to ensure that
training is provided to prescribers of these
medications and to develop information
that prescribers can use when counseling
patients about the risks and benefits of
opioid use.12 In 2013, the FDA established
a multipronged task force to address the
misuse and abuse of opioids.13 The task
force has undertaken a targeted approach
aimed at combating misuse, abuse and
addiction at critical points in the lifecycle
of an opioid product from development
through use, including:
• Drug Development
• Opioid Labeling
• Prescriber Education
• Patient Education
• Exploring Innovative Packaging/
Storage to Prevent Abuse
• Encouraging the Development
of Products that Treat Abuse and
Overdose
Formulation changes for these products
that reduce their potential for abuse are part
of this strategy, and the FDA announced
final industry guidance on the development
of abuse-deterrent opioids in April 2015.14
The Drug Enforcement Administration
also continues its efforts to address
the misuse and abuse of prescription
drugs. A key component was a final rule
rescheduling hydrocodone combination
products (HCPs) from Schedule III to the
stricter Schedule II that went into effect on
Oct. 6, 2014.15 The DEA also rescheduled
the prescription pain killer tramadol to
Schedule IV effective Aug. 18, 2014.16
There also is concern about the long-term
use of acetaminophen oral medications.
Acetaminophen is a widely used pain
reliever both in prescription and overthe-counter products. Using combination
prescription pain medication that includes
acetaminophen alone, or with over-thecounter acetaminophen products, raises
the potential for adverse events, notably
liver toxicity that may result from taking
more than the 4-gram daily limit. New
requirements for prescription opioid
combination products became effective in
January 2014 requiring each dose contain
no more than 325 mg of acetaminophen.
On the over-the-counter front, many
product manufacturers have relabeled their
acetaminophen products to alert consumers
not to take more than 3 g per day to reduce
the risk of severe liver toxicity. In January
2014, FDA urged healthcare professionals to
no longer prescribe or dispense prescription
products containing more than 325 mg
acetaminophen per dosage unit. The FDA
noted that it intended, in the near future, “to
institute proceedings to withdraw approval
of prescription combination drug products
containing >325 mg of acetaminophen per
dosage unit that remain on the market.”17
Common conditions causing pain
Numerous conditions may cause pain
and many may benefit from self-treatment.
These include such musculoskeletal injuries
as sprains and strains; neck, shoulder
and backaches; osteoarthritis; headaches;
and dysmenorrhea. Self-treatment may
Table 1
Patient assessment questions
• What symptoms are you experiencing?
• When did they start? Did a particular event or action
cause the symptoms?
• Have you had these symptoms before? When? Do
you know what caused them?
• Have the symptoms changed at all? Can you identify
what makes them better or worse?
• What steps have you taken thus far to address the
problem?
• What has resulted?
• What other concerns do you have?
july 2015 •
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Pharmacist CE Lesson
include over-the-counter systemic and
topical analgesics and hot/cold therapy
and massage. This lesson focuses on
nonsystemic
self-treatment
options.
The pharmacist should ask the patient
several assessment questions prior to
recommending any self-treatment options.
Table 1 provides a series of questions
to ask the patient to help characterize
pain and its cause. The completed
assessment may guide the pharmacist’s
self-treatment recommendations.
Pharmacologic topical pain management
Topical over-the-counter analgesics
used for minor musculoskeletal pain are
called counterirritants. Counterirritants
act upon the soft tissues and peripheral
nerves at the application site and produce
reversible, transient irritation or mild
inflammation. This counterirritation is
a paradoxical pain-relieving effect that
masks pain that is present more deeply
in the body. Counterirritants excite, then
desensitize nociceptive sensory neurons.18
This mechanism of action works along with
the massaging or rubbing action during
topical application to counter more deepseeded pain in joints, muscles and tendons.
Table 2 lists the four general categories
of counterirritants and their mechanism
of action. Topical analgesics may offer
a number of advantages to systemic
analgesics, including easy and controllable
application, faster symptom relief, symptom
relief at a steady and potentially longerterm rate, less risk of drug interactions
with other systemic agents, and they do not
cause gastrointestinal upset.18
Topical counterirritants are formulated
in many dosage forms, including lotions,
solutions, ointments, liniments, creams,
gels, sprays, sticks and patches with
single or combination ingredients. A list
of commonly used commercial products
is provided in Table 3. Ointments and
liniments offer increased absorption,
but may be greasy and less acceptable
to patients. Patches are increasing in
popularity because they are simple to use
and may require less frequent application.
However, they do not carry the additional
rubbing/massage benefit of application
as other dosage forms. Counterirritants
should not be applied more than four times
a day.18 Potential adverse effects include
local skin reactions, including redness,
rash, burning and stinging.
Serious burns have occurred with
the use of OTC topical analgesics,
leading the FDA to issue a drug safety
communication in September 2012 to
consumers and healthcare professionals.
The agency reviewed 43 case reports of
first- to third-degree chemical burns that
were associated with products containing
menthol, methyl salicylate and capsaicin.
Many of the second- and third-degree
burns occurred within 24 hours after a
single use of higher concentration products
(greater than 3% menthol and 10% methyl
salicylate). The pharmacist should review
product and ingredients prior to making
recommendations to patients. Additionally,
the pharmacist should counsel patients
that while a warm or cooling sensation is
associated with these products, a burning
pain or blistering is not normal, and if
Table 2
Classification of nonprescription counterirritant external analgesics5,18
Group
A
B
C
D
Mechanism
of action
Rubefacients act to vasodilate cutaneous vessels, increasing blood flow and
local skin temperature.
Produce cooling sensation followed by
warmth by acting on heat/cold sensitive
receptors called transient receptor
potential cation channels (TRPs)
Cause vasodilation
Incite irritation without rubefaction;
are as potent as group A. Elicit warmth
sensation by stimulating TRP vanilloid-1
receptor. Also release substance and
subsequently deplete substance P at
peripheral sensory neurons.
3 • july 2015
Ingredients
concentration (%)
Allyl isothiocyanate
0.5 - 5.0
Ammonia water
1.0 - 2.5
Methyl salicylate
10 - 60
Turpentine oil
6 - 50
Camphor
3 - 11
Menthol
1.25 - 16.0
Histamine dihydrochloride
0.025 - 0.1
Methyl nicotinate
0.25 - 1.0
Capsicum
0.025 - 0.25
Capsicum oleoresin
0.025 - 0.25
Capsaicin
0.025 - 0.25
they occur, the patient should stop using
the product immediately and let the
pharmacist know.19
Special considerations for products with
methyl salicylate and trolamine salicylate
include the potential for systemic reactions,
especially after heat exposure and exercise.
They should be used with caution in
patients with aspirin sensitivity or asthma.
Use of these products also can cause
prolonged prothrombin time in patients on
warfarin maintenance therapy.20 Trolamine
salicylate is not a counterirritant and has
shown limited effectiveness but may be
preferred by patients if they do not like the
scent of other counterirritants. Salicylates
should not be used by patients with renal
insufficiency, liver disease, vitamin K or
thrombin deficiency, or by those who are
chronic alcohol users or who are scheduled
for surgery.18
Capsicum is the fruit of the African
chile, tabasco pepper or other peppers,
and its active ingredient is capsaicin. Its
mechanism of action is different from the
other counterirritants and pain relief usually
occurs within 14 days of starting therapy,
but can take as long as four to six weeks.5
Patients must continue to apply capsicum
to achieve pain relief. Burning and stinging
is prevalent with capsicum use, occurring
in 40% to70% of patients, but it generally
subsides with further application.18
Use of heating pads or heat wraps
can
increase
absorption
of
some
counterirritants, including menthol and
methyl salicylate, causing skin damage and
necrosis. Tight bandaging after application
of topical analgesics also can contribute to
redness, irritation or blistering and should
be avoided. The application site may be
lightly bandaged.
Nonpharmacologic pain management
The use of cryotherapy (cold) and
thermotherapy (heat), as well as massage
therapy
are
useful
self-treatment
considerations in pain management.
Cryotherapy and thermotherapy
Cryotherapy is used to reduce swelling
and inflammation associated with muscle
and joint injuries. Cryotherapy also reduces
tissue metabolism, thereby reducing the
extent of secondary damage that might
result from hypoxia. For acute injuries,
such as strains and sprains, and acute low
backaches, cold therapy is recommended
for use as soon as possible after injury and
up to 72 hours after injury according to the
RICE guidelines (Table 4).
Cold therapy should be applied in
15- to 20-minute increments three to
four times daily. Use of cold therapy
for more than 20 minutes should be
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Pharmacist CE Lesson
Table 3
Selected external analgesics
Product and type
ingredients
Group B
Absorbine Plus Jr. ® Pain Relieving Liquid
Menthol 4%
Absorbine Jr. ® Pain Relieving Cream
Menthol 205%
Aspercreme® Heat Pain Relieving Gel
Menthol 10%
Bengay® Cold Therapy
Menthol 5%
Bengay® Zero Degrees Pain Relieving Gel
Menthol 5 mg
Bengay® Ultra Strength Pain Relieving Patches, regular and large
Menthol 5%
Icy Hot® Pain Relieving Gel
Menthol 2.5%
Icy Hot® Power Gel
Menthol 16%
Icy Hot® Patches (various sizes)
Menthol 5%
JointFlex® Arthritis Pain Relieving Cream
Camphor 3.1%
JointFlex® Ice Pain Relief Lotion
Menthol 8.5%
Mentholatum® Pain Relief Extra Strength Gel
Menthol 3%
Mission™ Max Muscle Rehab No Mess Roll-on Gel
Menthol 9%
Perform® Pain Relieving Gel
Menthol 3.1%
Perform® Pain Relieving Roll-On of Biofreeze
Menthol 3.1%
Perform® Pain Relieving Spray
Menthol 10.4%
Group C
Australian Dream® Pain Relieving Arthritis Cream
Histamine dihydrochloride 0.025%
Group D
Capzasin-HP® Lotion/Cream
Capsaicin 0.1%
Zostrix-HP® Cream
Capsaicin 0.075%
Combination products
ActivOn® Topical Analgesic Ultra Strength Arthritis
Histamine dihydrochloride 0.025%, menthol 4.127%
ArthArrest™ Topical Analgesic Lotion
Capsaicin 0.025%, methyl nicotinate 0.5%
Arthritis Formula Bengay® Cream
Methyl salicylate 30%, menthol 8%
Bengay® Ultra Strength Pain Relieving Cream
Methyl salicylate 30%, menthol 10%, camphor 4%
Icy Hot® Advance Relief Pain Relief Cream
Camphor 11%, menthol 16%
Icy Hot® Extra Strength Pain Relieving Stick
Methyl salicylate 30%, menthol 10%
Icy Hot® Pain Relieving Cream
Methyl salicylate 30%, menthol 10%
Mentholatum® Pain Relief Deep Healing Lotion
Methyl salicylate 20%, menthol 8%
Pain Bust-R II® Extra Strength Pain Relief Cream
Methyl salicylate 17%, menthol 12%
Salonpas® Arthritis Pain Patch
Methyl salicylate 10%, menthol 3%
Salonpas® Gel Patch Hot
Capscaicin 0.025%, menthol 1.25%
Salonpas® Original Pain Relief Patch
Camphor 1.2%, methyl salicylate 6.3%, menthol 5.7%
Salonpas® Deep Relieving Gel
Camphor 3.1%, Methyl salicylate 15%, menthol 10%
Salonpas® Pain Relief Patch
Methyl salicylate 10%, menthol 3%
Tiger Balm® Neck and Shoulder Rub Pain Relieving Cream
Camphor 11%, menthol 10%
Tiger Balm® Muscle Rub Pain Relieving Cream
Methyl salicylate 15%, menthol 5%
Tiger Balm® Pain Relieving Ointment Extra Strength
Camphor 11%, menthol 10%
Tiger Balm® Pain Relieving Ointment Ultra Strength
Camphor 11%, menthol 11%
Tiger Balm® Pain Relief Patch
Camphor 80 mg, capsaicin 16 mg, menthol 24 mg
Zim’s Max-Freeze™ Maximum Muscle & Joint Pain Relief Gel
Camphor .2%, menthol 3.7%
Zim’s Max-Freeze™ Roll-On
Menthol 3.7%
(Continued on page 5)
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july 2015 •
4
Pharmacist CE Lesson
Table 3 (continued)
Selected external analgesics
Product and type
Ingredients
Miscellaneous
Aspercreme® Crème (and Odor Free)
Trolamine salicylate 10%
Sportscreme® Deep Penetrating Pain Relieving Rub Cream/Lotion
Trolamine salicylate 10%
Source: Reference 18, product websites
avoided because excessive icing can cause
vasoconstriction and can reduce clearance
of inflammatory mediators from the injured
area. Cryotherapy lowers the temperature
of subcutaneous tissue and decreases
inflammation by inhibiting histamine,
neutrophils, collagenase and synovial
leukocyte activity. Cold application may
penetrate to muscle and joints, depending
on how long and how it is used. Application
of cold has little use in persistent pain.
18
Numerous devices are available for
cryotherapy, including disposable and
reusable cold packs, wraps and compresses.
Thermotherapy, or application of heat, is
useful for patients with noninflammatory
pain that is often seen in repetitive strains
and osteoarthritis. Heat is thought to
dilate the blood vessels, stimulate blood
circulation and reduce muscle spasms. In
addition, heat may alter pain sensation.
Heat is applied every 15-to-20 minutes
for three to four times a day. Heat therapy
should not be used in acute injury or
inflammation (i.e., during the first 48 hours)
because it can exacerbate tissue damage
and vascular leakage.18
Heat traditionally has been applied by
using dry heat through electric heating
pads, lights or moist compresses, such as
hot water bottles, warm washcloths or
baths. Newer adhesive heat products and
wraps generate heat over a longer period of
time and may be easier to use and apply to
a variety of body areas, including the lower
back. Advantages to newer products are
that they may be worn while active, may
be used to prevent or treat delayed muscle
soreness, and may be more effective than
cold therapy. Patients should be advised
to remove a heat wrap or patch if they
experience pain, discomfort, itching or
burning. The pharmacist also should advise
patients not to sleep with heat wraps on
due to the risk of burning. Those older than
55-years old should wear the wrap over
clothing for the same reason. Additionally,
heat should not be used with topical
analgesics as noted above. Nor should
patients with diminished sensation or poor
circulation use them because of the risk of
burning. The pharmacist should evaluate
patients for signs of poor circulation,
which include poor nail quality, decreased
skin temperature, thinning of the skin and
ulcerations.21 Neither cold nor heat therapy
should be used on broken skin areas.18
Massage therapy
Massage is the treatment of superficial
areas of the body, including muscles,
tendons, ligaments, skin, joints or other
connective tissue, as well as lymphatic
vessels and organs of the gastrointestinal
system, through rubbing, kneading,
stroking, slapping or vibration, which can
be structured or not depending on the
modality of the massage. Massage literally
Table 4
RICE therapy18
Recommendation
Goal
Rest
Rest the injured area until the pain has
decreased significantly, usually one to
two days
To relieve pain
Ice
Apply ice to the injured area as soon
as possible. Apply in 15-minute increments multiple times per day. Continue
for at least one to three days after injury
To decrease swelling and
inflammation and relieve pain
Compression
Apply a compression wrap to the
injured area
To relieve pain
Elevation
Elevate the injured area above the level
of the heart as often as possible, but
at least two to three hours per day and
anytime while resting
To decrease swelling and
relieve pain
5 • july 2015
means “friction of kneading.”22 Massage
can increase circulation and relax muscles
locally, leading to pain reduction.
Therapeutic massage has been used to
increase mobility and alleviate pain for a
variety of medical conditions, including
cancer, HIV/AIDS and in palliative and
long-term care.23,24,25,26,27,28,29 The use of
therapeutic massage is increasing and a
growing body of literature supports its
use as an effective tool in pain relief and
management with fewer adverse reactions
than other treatments.26 Massage therapy
is one of the most often prescribed and
used complementary and alternative
therapies by patients.30,31 Recent studies in
the acute-care setting have shown massage
reduces pain and may be the equivalent to
a morphine dose, while reducing the rate of
pain decline by a day.32,33 A literature review
of the effectiveness of massage therapy for
chronic, nonmalignant conditions found
the following:
• Robust support for nonspecific low
back pain
• Moderate support for shoulder and
headache pain
• Modest, preliminary support for
fibromyalgia, mixed chronic pain
conditions, neck pain and carpal
tunnel syndrome26
There are numerous types of massage.
Not all patients may be able to access a
massage therapist or feel comfortable
receiving massage therapy. Therapeutic
massage devices are available for selftreatment. The FDA defines a therapeutic
massager as an electrically powered device
intended for medical purposes, such as to
relieve minor muscle aches and pains.34 A
list of selected massage devices is in Table 5.
Therapeutic massage devices come both
battery-powered and with AC adaptors.
They may be very compact and portable,
or larger. Some are shaped for various
body areas, including the neck, shoulders,
back and feet. Others come with varying,
interchangeable heads for use on differing
parts of the body. They may have variable
speed settings for a light or deep-penetrating
massage dependent upon the pain level.
There may be settings for use with or
without heat. These are considerations for
the pharmacist when helping a patient
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Pharmacist CE Lesson
Table 5
Selected therapeutic massagers
Wahl® All-Body Powerful Therapeutic Massager
Two-speed, powerful therapeutic massager with customizable attachments to alleviate
pain
Wahl® Deep Tissue Percussion Therapeutic Massager
Four interchangeable attachments for deep muscle massage; variable speed control
Wahl® Heat Therapy Therapeutic Massager
Therapeutic heated massage with variable intensity, two-speeds, two-heat settings and
four attachments to reduce pain
Wahl® Heat Therapy Heated Therapeutic Massager
Therapeutic heated massage with a powerful variable intensity, heat and nine attachments to reduce pain
Wahl® Hot-Cold Therapeutic Massager
This corded massager has variable intensity for light or intense massage, with seven
attachment heads, and a heat-and-cold attachment
Wahl® Mini Therapy Battery Therapeutic Massager
Vibrating, therapeutic, battery-operated massager with six attachments for convenient
pain relief anywhere
Wahl® Spot Therapy Therapeutic Massager
Allows a customized experience; two-speeds for soothing or deep-penetrating relief;
five attachments
Panasonic EV2510K Handheld All-Body Rolling Massager
Three roller and vibration systems offer relaxed, all-body massage with portable design
Panasonic EV2610K Easy Reach Massager Handheld 2 speed
Seven massage actions integrated into two pre-programs; variable speed control
HoMedics® Shiatsu Foot Massager
Rotating mechanism; heat, deep kneading, counter-rotational massage; two-touch
control for massage only or massage and heat combined
HoMedics Neck and Shoulder Massager with Heat
Two-speed massage and heat for integrated control; portable; operates on both batteries or AC adaptor
HoMedics® Shiatsu and Vibration Pillow Massager
3-D rotating massage mechanism; heat; pillow conforms to body; deep kneading for
neck, back and shoulders
HoMedics® Mini Massager
Quad massaging nodes; portable; handheld
Health Solutions™ Rechargeable Adjustable Cordless Massager Kit
Three adjustable positions (40°/80°/180°); two speeds (gentle and energizing); rechargeable; four massage surfaces (smooth top plus three side surfaces)
Body Benefits by Body Image® Mini Massager
Versatile, portable hand-massage tool
select a therapeutic massage device.
The pharmacist should counsel the
patient to follow the manufacturer’s
instructions for the device’s use. In general,
once the correct settings are selected, the
patient should apply the massager to the
targeted area, using continual movement.
A circular motion often is most effective. If
heat is being used, patients should check the
device’s temperature by lightly touching it
with their fingertips. If the temperature is
uncomfortable, it can be reduced before
use, either by reducing the heat switch or,
if the massager does not have more than
one heat setting, by turning the unit off for
a short time before use and checking the
temperature again. Massagers should not
be used on swollen or inflamed areas or on
broken skin.
Care should be taken to inspect the
device; it should not be used if the housing
is cracked or other parts are loose, bent
or broken. After use, patients should be
advised to always unplug the massager
and then clean it by wiping the unit with a
dry, soft cloth. Unless specifically designed
for use in water, massage devices should
not be immersed in water.
Commonly encountered conditions and
treatment options
Patients frequently seek advice from
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the pharmacist for treating pain associated
with common conditions. Table 6 provides
information on treatment options and selftreatment exclusions for these conditions.
Musculoskeletal injuries
Sprains and strains cause pain
and
inflammation.
Sprains
occur
when ligaments and tendons become
overstretched or torn and most commonly
affect the ankle and knee, although the
wrist, fingers and toes also incur sprains.
Strains occur when a muscle or tendon is
overstretched or torn, and can be acute or
chronic in nature. Strains most commonly
affect the back muscles or major muscle
groups such as the quadriceps, hamstrings
or abdominal muscles. Sprains generally
are acute injuries, while strains generally
are from overextension or use.
In addition to the assessment questions
in Table 1, the pharmacist should ask
the patient about any joint deformities,
problems bearing weight on the joint, other
movement issues, or signs of secondary
infection. In these cases, patients should be
referred to their physician. If self-treatment
does not provide relief after seven days, or
the condition worsens, the pharmacist also
should refer the patient for follow-up.
Treatment for sprains and strains may
include systemic or topical analgesics
(Table 4) and the nonpharmacologic RICE
therapy, cryotherapy, thermotherapy and
massage. Heat therapy is appropriate for
noninflammatory injuries.
The pharmacist should explain to the
patient ways to help prevent sprains and
strains. These include proper muscle
warm-up and stretching before physical
activity to the point of developing a light
sweat, maintaining proper hydration to
avoid muscle spasms, and use of braces
or taping for patients prone to certain
injuries. Gentle physical activity may be
encouraged in patients with low back pain
to avoid worsening the condition from over
bed rest.18
Osteoarthritis
Osteoarthritis, or degenerative joint
disease, is characterized by the softening
and destruction of cartilage in joints over
time, with bone thickening and new bony
growths. This causes joint rearrangement
and subsequent pain, decreased motion
and mild or localized inflammation.18 In
addition to systemic and topical analgesics
and the nonpharmacological therapies
discussed earlier, patients may benefit from
weight loss to reduce stress on weightbearing joints and exercise to improve joint
flexibility. Nonpharmacologic methods
may be preferred for some patients where
july 2015 •
6
Pharmacist CE Lesson
Table 6
Common pain condition treatment options and self-treatment exclusions5, 18
Condition
Treatment
OTC analgesics
Systemic
Thermatherapy/cryotherapy
Nonsystemic
hot
Massage
therapy
Other
treatment
notes
Self-treatment exclusions by
category and condition
cold
Musculoskeletal injuries
- Moderate to severe pain (a pain score >6 on
a 10-point scale)
- Pain lasting >10 days
- Pain lasting >7 days after treatment
- Change in pain intensity or character
- Pelvic or abdominal pain (other than dysmenorrhea)
- Accompanying nausea, vomiting, fever or
other signs of systemic infection or disorder
- Visually deformed joint, abnormal movement, limb weakness, suspected fracture
- Back pain and loss of bladder/bowel control
- Pregnancy
- <2 years old
Sprains and strains
X
X
X
X
RICE therapy,
use of protective wraps,
stretching
Neck and/or shoulder
pain
X
X
X
X
X
Stretching
Backache
X
X
X
X
X
Osteoarthritis
X
X
X
X, joint pain
X
Continuous
exercise with
light to moderate activity,
weight loss (if
overweight),
use of
ambulation
devices
- Moderate to severe pain
- Pain lasting >2 months after step treatment
- Change in pain intensity or character
- Pelvic or abdominal pain (other than dysmenorrhea)
- Accompanying nausea, vomiting, fever or
other signs of systemic infection or disorder
- Visually deformed joint, abnormal movement, limb weakness, suspected fracture
- Back pain and loss of bladder/bowel control
- Pregnancy
- <2 years old
- Should be diagnosed prior to self-treatment
Headache, tension-type,
sinus or migraine
X
X
X
X
Maintain
regular sleep
schedule;
avoid triggers, including hunger
and low blood
sugar for
migraine
- Severe head pain
- Headaches lasting longer than 10 days, with
or without treatment
- Pregnancy, third trimester
- <8 years old
- High fever or signs of infection
- Liver disease or >3 alcoholic drinks per day
- Associated underlying pathology (secondary
headache)
- Migraine symptoms with no diagnosis
Dysmenorrhea
X
Avoid
smoking and
second-hand
smoke;
engage in
regular exercise; consider
omega-3
fatty acid
supplements
Severe dysmenorrhea and/or menorrhagia;
Symptoms inconsistent with primary disease
(e.g., onset >25 years old, pain other than at
menses onset); history of pelvic inflammatory
disease; infertility; irregular menstrual cycle,
endometriosis; ovarian cysts; intrauterine
device use; allergy to aspirin or NSAIDs; active
GI disease; bleeding disorder
7 • july 2015
X
Gait abnormalities; bowel or bladder incontinence; limb weakness, numbness or tingling;
radiating pain from back of thigh to lower leg
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Pharmacist CE Lesson
Patient Scenario 1
DJ is a 45-year-old male who comes to the pharmacy seeking relief from a sore back and leg, and
asks the pharmacist to recommend something for the pain. The pharmacist begins the assessment
by asking DJ when the pain started and if there was any known cause of the pain. DJ explained that
he joined a recreational bowling league two weeks ago in an effort to become more active and meet
new people. DJ commented that he had been pretty inactive before joining the league. He has an
office job as an IT developer. He may have strained some muscles during this week’s game. As the
pharmacist reviews DJ’s profile and asks about other medical conditions (including over-the-counter
products), the pharmacist learns that DJ has high cholesterol and is taking a statin. In addition, DJ has
been self-medicating with leftover hydrocodone-acetaminophen from a dental procedure he had done
the year before. The leftover pain medication is making DJ too tired to complete projects for work. He
also offers that the pain is really interfering with his ability to concentrate on a big project he needs to
complete. He is seeking something else for the pain in his hamstring.
Discussion
The pharmacist suggests a number of possible therapies to DJ, explaining the benefits and proper use
instructions and items that DJ would be willing to use. During the discussion they review several heat
packs and wraps and a pain patch with a low concentration of menthol that would provide relief for
DJ’s back without limiting his ability to work. The pharmacist counsels DJ to use the heat wrap for 15
to 20 minutes up to three or four times daily but not to wear it to sleep to avoid potential burns. The
pharmacist also advises DJ not to use the heat wrap and the patch at the same time. With regard to the
hamstring injury, which occurred the evening before, the pharmacist recommends that DJ try a topical
counterirritant on the leg. They select a lotion with capsicum. The pharmacist notes that it may take
up to two weeks for pain relief and the lotion should be used daily. In addition, the pharmacist learns
that DJ likes to enjoy beer with his colleagues during the games and counsels DJ to avoid taking
acetaminophen because of issues with alcohol. Instead, a non-steroidal anti-inflammatory medicine is
chosen and proper counseling is provided to prevent the potential stomach upset. The pharmacist also
uses the opportunity to educate DJ on problems associated with leaving older medicines in the home
and the potential for abuse. The pharmacy has a drop-off area for older medications and DJ decides to
leave the rest of the old prescription medicine in the disposal box. The pharmacist advises DJ that she
will call him in two days to see if the leg and back pain have subsided.
systemic therapy is contraindicated (e.g.,
NSAIDs in the elderly).
Use of alternating cryotherapy and
thermotherapy may be most effective for
these patients. The pharmacist should
provide guidance in product selection to
help patients determine which works best
for their condition. Massage therapy also
has been shown to have benefit.35 Some
therapeutic massage devices are made with
Patient Scenario 2
DS is a 55-year-old female who comes to the pharmacy seeking relief for a headache. As part of the
assessment, the pharmacist learns that DS has been experiencing head pain on and off for a few
days. She says it began when a weather system moved into the area, bringing rain. The pharmacist
also knows the rain has increased the pollen count and asks DS if she experiences allergies. She says
she does get headaches and a runny nose usually in the spring. In reviewing her patient profile, the
pharmacist learns that DS does take medication for high blood pressure, which is under control. She
is wondering what she might purchase for the headache pain and running nose. DS has heard about
self-massage devices and wants to know if they may be helpful on her temples.
Discussion
The pharmacist recommends that DS try a nonsedating antihistamine for her allergies after learning she
had been taking a cold product from home that had a decongestant and cough suppressant in it. The
pharmacist advises DS to avoid decongestants because of her blood pressure. For the headache pain, a
nonsteroidal anti-inflammatory is recommended as DS says she avoids taking acetaminophen because
she’s heard of overdose problems. The pharmacist does inform DS that there is evidence that massage
therapy can help with headaches. The various massage devices that the pharmacy carries are quickly
reviewed, and a small, portable, battery-operated personal massage device is selected. DS thinks this
will be easy to carry to her office if she needs to take a break to use it. The pharmacist advises DS that
if her symptoms continue for another week she should see her physician. Also, the pharmacist makes
a note to call DS in a few days to see if the recommended medications have helped with the problem.
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joint attachments, as well. Glucosamine
and chondroitin supplements may be
recommended if appropriate. A review
of 43 studies among more than 9,000
people found that in randomized trials of
mostly low-quality chondroitin (alone or
in combination with glucosamine) was
better than placebo in improving pain in
participants with osteoarthritis in shortterm studies. And the supplement was
considered generally safe.36 The pharmacist
should follow up after one month and
make further treatment adjustments. If
an additional four weeks of treatment
does not improve the condition, patients
should be referred to their physician for
further treatment. Table 6 outlines other
self-treatment exclusions. Self-treatment
is not advised until after a diagnosis of
osteoarthritis has been made.
Headache
More than 90% of people experience
headaches at some point in their lives.37
Headaches may be classified as tension
(stress) headaches, migraines or sinus
headaches based on their location, nature,
onset and duration. Chronic headaches are
defined as occurring at least 15 days per
month for six months. Headaches also may
be caused by rebound from medication
overuse of analgesics for three months
or more. Commonly involved systemic
medications are acetaminophen, aspirin,
caffeine, triptans, opioids, butalbital or
ergotamine formulations. In this case, the
headache will begin when the medication
is stopped, but it will resolve when the
medication is taken again. Prescription
therapy may be required during the
withdrawal period.38
Cryotherapy can be effective for some
migraine sufferers, as well. Some cold packs
specifically are designed for headache
treatment. Physical treatments in headache
management usually include acupuncture,
oxygen therapy, transcutaneous electrical
nerve stimulation, occlusal adjustment,
cervical manipulation, physical therapy,
massage,
chiropractic
therapy,
and
osteopathic manipulation.39 There is modest
evidence that massage therapy is effective
for tension and migraine headaches.26 Sinus
headaches respond well to decongestants.
Self-treatment exclusions for patients with
headache pain are listed in Table 6.
Dysmenorrhea
Dysmenorrhea, difficult or painful
menstruation, is a common gynecological
problem in the United States. Primary
dysmenorrhea presents with abdominal
cramping at the time of menstruation, but
is not accompanied by associated pelvic
disease, which is the case with secondary
july 2015 •
8
Pharmacist CE Lesson
dysmenorrhea.40 Secondary dysmenorrhea,
which usually occurs in the mid- to late 20s
through the 30s and 40s, is more irregular
and may occur before, during or after
menses. Systemic NSAID therapy may
be recommended and should be taken
just prior to or at the onset of menses
for primary dysmenorrheal; NSAIDs
are not effective in secondary cases.
Thermotherapy applied locally also can
provide relief from cramping, either alone
or in combination with systemic therapy
and in those patients where NSAID therapy
is not appropriate. Several thermotherapy
products have been designed specifically
for use with menstrual cramping and can
provide faster relief than systemic therapy.
Lifestyle changes also have been suggested
to provide some relief for this condition.
These are noted, along with exclusions for
self-treatment in Table 6.
Conclusion
A large number of Americans suffer
from pain and often seek information
from pharmacists about treating pain
Practice points
•
•
•
•
•
•
Numerous conditions may cause pain and many patients may benefit from self-treatment.
Conduct a patient assessment using the questions in Table 1 to determine if self-treatment for
the condition causing the pain is appropriate.
Based on the patient’s condition and medication history, determine if there are any
nonpharmacologic or nonsystemic treatment alternatives that may be recommended.
When using external analgesics, advise patients not to use heating devices with topical
counterirritants, or to cover them tightly with bandages to avoid irritation, redness or blistering.
If pain, swelling or blistering occurs with external analgesic use, advise the patient to discontinue
use of the product and make appropriate recommendations to treat the skin issue.
When using cold or heat therapy, counsel patients not to overuse cold treatment and not to sleep
with heat wraps to avoid tissue damage and burns.
Massage therapy is appropriate and effective for a number of conditions associated with pain,
including backache, headache, neck and shoulder pain among others. Assist patients in selecting
a device based on their condition and counsel them on the device’s appropriate use and care.
associated with common conditions that
may benefit from self-treatment, including
musculoskeletal injuries, osteoarthritis,
headaches and dysmenorrhea. The
pharmacist should be able to assess the
patient’s condition to determine if it is
appropriate for self-treatment and counsel
patients on both nonpharmacologic and
pharmacologic therapies to address their
condition. Nearly three-fourths of patients
prefer to try to self-treat their condition than
see a physician, and they are increasingly
combining pain management treatments.41
Having access to the pharmacist’s
advice and counsel can assist patients in
determining self-treatment.
1 Gulur P, Soldinger SM, Acquadro MA. Concepts in pain management. Clin Podiatr Med Surg. 2007;24(2):33-35. 2 Institute of Medicine Report from the Committee on Advancing Pain
Research, Care, and Education: Relieving pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011. http://iom.edu/
Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research/Report-Brief.aspx. Accessed April 21,2015. 3 National Centers for Health
Statistics, Chartbook on Trends in the Health of Americans 2006, Special Feature: Pain. http://www.cdc.gov/nchs/data/hus/hus06.pdf. Accessed April 29, 2013. 4 IASP Taxonomy. Pain
terminology. May 22, 2012. International Association for the Study of Pain Web site. http://www.iasp-pain.org/Taxonomy. Accessed April 21, 2015. 5 OTC Advisor. Self- Care for Pain.
Monograph 4. American Pharmacists Association. March 15, 2010. 6 Health Care Association of New Jersey (HCANJ). Pain management guideline. Hamilton (NJ): Health Care
Association of New Jersey (HCANJ); July 18, 2006. Reaffirmed 2011. http://www.guideline.gov/content.aspx?id=9744. Accessed April 22,2015. 7 Thacker MA, Clark AK, Marchand F, et
al. Pathophysiology of peripheral neuropathic pain: immune cells and molecules. Anesth Analg. 2007;105:838-847. 8 International Association for the Study of Pain. (1986). Classification
of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Pain Suppl, 3, S1-226. 9 Peter D. Hart Research Associates. Americans in Pain. http://www.
researchamerica.org/uploads/poll2003pain.pdf. Accessed April 22, 2015. 10 National Pain Strategy. A Comprehensive Population Health-Level Strategy for Pain. Interagency Pain
Research Coordinating Committee. National Institute of Neurological Disorders and Stroke. http://iprcc.nih.gov/docs/DraftHHSNationalPainStrategy.pdf. Accessed April 22, 2015. 11
National Drug Control Strategy 2014. The Office of the President of the United States. Whitehouse.gov Web site. Available at: http://www.whitehouse.gov/ondcp/national-drug-controlstrategy. Accessed April 22, 2015. 12 Risk Evaluation and Mitigation Strategy for Extended-Release and Long-Acting Opioids. FDA Web site. April 25, 2013. http://www.fda.gov/drugs/
drugsafety/informationbydrugclass/ucm163647.htm. Accessed April 23, 2015. 13 FDA’s efforts to combat the misuse and abuse of opioids. FDA Web site. April 9, 2014. http://www.fda.
gov/Drugs/DrugSafety/InformationbyDrugClass/ucm337852.htm. Accessed April 22, 2015. 14 FDA issues final guidance on the evaluation and labeling of abuse-deterrent opioids [press
release]. April 1, 2015. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm440713.htm. Accessed April 22, 2015. 15 Drug Enforcement Administration. 21 CFR Part
1308. [Docket No. DEA-389]. Schedules of Controlled Substances: Rescheduling of Hydrocodone Combination Products From Schedule III to Schedule IICFR http://www.deadiversion.
usdoj.gov/fed_regs/rules/2014/fr0822.htm. Accessed April 22, 2015. 16 21 CFR Part 1308. [Docket No. DEA–351] Schedules of Controlled Substances: Placement of Tramadol Into
Schedule IV. Federal Register Vol. 79, No. 127 / Wednesday, July 2, 2014. http://www.gpo.gov/fdsys/pkg/FR-2014-07-02/pdf/2014-15548.pdf. Accessed April 22, 2015. 17 U.S. Food and
Drug Administration. FDA recommends health care professionals discontinue prescribing and dispensing prescription combination drug products with more than 325 mg of acetaminophen
to protect consumers. Accessed at http://www.fda.gov/Drugs/DrugSafety/ucm381644.htm. Accessed April 22, 2015. 18 Olenak JL. Musculoskeletal injuries and disorders. In: Handbook
of Nonprescription Drugs. 18th ed. Washington, DC: American Pharmacists Association;2015:97-114. Accessed online at www.pharmacylibrary.com [subscription required.] 19 FDA drug
safety communication: Rare cases of serious burns with the use of over-the-counter topical muscle and joint pain relievers. FDA Web site. September 13, 2012. http://www.fda.gov/Drugs/
DrugSafety/ucm318858.htm. Accessed April 23, 2015. 20 Methyl Salicylate. In: Sweetman S, ed. Martindale—The Complete Drug Reference. 37th ed. Gurnee, IL: Pharmaceutical Press;
2011:89-90. 21 Brosseau L, Yonge KA, Robinson V, et al. Thermotherapy for treatment of osteoarthritis. Cochrane Database Syst Rev. 2011;4:CD004522. doi: 10.1002/. 22 Massage
therapy. MedicineNet.com Web site. April 2, 2014. http://www.medicinenet.com/massage_therapy/article.htm. Accessed April 23, 2015. 23 Sefton JM, Yarar C, Berry JW. Six weeks of
massage therapy produces changes in balance, neurological and cardiovascular measures in older patients. Int J Ther Massage Bodywork. 2012:5(3):28-40. 24 Beck I, Runeson I,
Blomqvist K. To find inner peace: soft massage as an established and integrated part of palliative care. Int J Palliat Nurs. 2009 Nov;15(11):541-545. 25 Cassileth BR, Keefe FJ. Integrative
and behavioral approaches to the treatment of cancer-related neuropathic pain. DOI: 10.1634/theoncologist.2009-S504. The Oncologist 2010;15;19-23. 26 Tsao J. Effectiveness of
massage therapy for chronic, non-malignant pain: a review. Evid Based Complement Alternat Med. 2007 June; 4(2): 165–179. 27 Cherkin DC, Sherman KJ, Kahn J, et. al. A comparison
of the effects of massage and usual care on chronic low back pain: a randomized, controlled trial. Ann Intern Med. 2011;155(1)1-9. 28 Evans R, Vihstadt C, Westrom K, Baldwin L.
Complementary and Integrative Healthcare in a Long-term Care Facility: A Pilot Project. Glob Adv Health Med. 2015 Jan;4(1):18-27. doi: 10.7453/gahmj.2014.072. 29 Hiller SL, Louw Q,
Morris L, Uwimana J, Statham S. Massage therapy for people with HIV/AIDS. Editorial Group: Cochrane HIV/AIDS Group. Published Online: 20 Jan 2010. Assessed as up-to-date: 2 Nov
2009. DOI: 10.1002/14651858.CD007502.pub2. 30 Ho KY, Jones L, Gan TJ. The Effect of cultural background on the usage of complementary and alternative medicine for chronic pain
management. Pain Physician 2009; 12:685-688. 31 Ezzo J. What can be learned from Cochrane systematic reviews of massage that can guide future research? J Altern Complement
Med. 2007; 13(2): 291–295. 32 Adam R, White B, Beckett C. The effects of massage therapy on pain management in the acute care setting. IJTMB. 2010;(3)1:4-11. 33 Edelson E.
Massage eases pain, anxiety after surgery. December 17, 2010. ABC News Web site. http://abcnews.go.com/Health/Healthday/story?id=4509773&page=1. Accessed April 23, 2015. 34
CFR-Code of Federal Regulations-21. FDA.gov Web site. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr=890.5660. Accessed April 23, 2015. 35 Perlman AI, Ali
A, Njike VY, et. al. Massage therapy for osteoarthritis of the knee: a randomized dose-finding trial. PLoS One. 2012;7(2)e30248. doi:10/1371/journal.pone.0030248. Epub 2012 Feb 8. 36
Singh JA, Noorbaloochi S, MacDonald R, Maxwell LJ. Chondroitin for osteoarthritis. Editorial Group: Cochrane Musculoskeletal Group. Published Online: 28 Jan 2015. Assessed as upto-date: 14 NOV 2013. DOI: 10.1002/14651858.CD005614. 37 Smith TR. Epidemiology and impact of headache: an overview. Prim Care Clin Office Pract. 2004;31:237-241. 38
Wilkinson JL. Headache In: Handbook of Nonprescription Drugs. 18th ed. Washington, DC: American Pharmacists Association;2015:63-84.Accessed online at www.pharmacylibrary.com
[subscription required.] 39 Sun-Edelstein C, Mauskop A. Alternative headache treatments: nutraceuticals, behavioral and physical treatments. Headache. 2011;51(3):469-83. doi:
10.1111/j.1526-4610.2011.01846.x. 40 Shimp LA. Disorders related to menstruation. In: Handbook of Nonprescription Drugs. 18th ed. Washington, DC: American Pharmacists Association;
2015:131-149. Accessed online at www.pharmacylibrary.com [subscription required.] 41 White paper on the benefits of OTC medicines in the United States. Report of the Consumer
Healthcare Products Association’s Clinical/Medical Committee. Pharmacy Today. October 2010:68-79. http://www.yourhealthathand.org/images/uploads/r_6842.pdf. Accessed April 23,
2015.
9 • july 2015
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Pharmacist CE Lesson
Learning Assessment
1. Pain is defined as the “unpleasant
sensory and emotional experience” associated with actual or potential tissue
damage or described in terms of such
damage.
a.True
b.False
2. Which statement regarding pain is
false?
a. It is often characterized as somatic or
visceral
b.It may be nociceptive or neuropathic
c. Nociceptive pain may be accompanied by inflammation
d.It may be nociceptive, meaning it
arises from organs only
3. With regard to acute or chronic pain:
a. Acute pain may be caused by a temporary problem
b.Acute pain may last a few days or a
couple of weeks
c. Chronic pain is defined as pain lasting
three to six months
d.All of the above
4. Which of the following statements
about pain management approaches in
patients is false?
a. May vary by cause and condition
b.Follow the new, final National Pain
Strategy Clinical Guidelines
c. Often require combination therapy
d.May be self-treated when appropriate
with OTC analgesics, both systemic
and/or topical, heat/cold therapy
and/or massage
5. Regarding pain and pain treatment:
a. The Interagency Pain Research Coordinating Committee will be finalizing
a National Pain Strategy in 2015 to
create a comprehensive population
health strategy for pain prevention,
management and treatment
b.The IOM has asked the Health Care
Association of New Jersey to revise
their 2007 Pain Treatment Guidelines
c. The DEA has recommended that
pharmacists follow pain treatment
guidelines recommended by the FDA
d.The FDA has formed a task force to
update pain treatment guidelines
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6. Which steps have been taken recently
to help address growing concerns
about the misuse and abuse of pain
management medications?
a. The DEA has rescheduled oxycodone
from schedule II to schedule III
b.The DEA has rescheduled hydrocodone-combination products from schedule III to schedule II
c. The FDA has taken all non-abuse
deterrent hydrocodone combination
products off the market
d.The FDA has recommended that the
DEA reschedule tramadol from schedule IV to schedule III
7. All of the following are common conditions that may cause pain except:
a.Sprains
b.Strains
c.Backaches
d.Bowel obstruction
8. Self-treatment of pain may be appropriate in which of the following
conditions?
a. Headache lasting more than 10 days
b.Severe dysmenorrhea
c. Mild joint pain associated with osteoarthritis
d.Musculoskeletal injury pain lasting
more than seven days after treatment
9. Topical analgesics may offer all but
the following advantages over systemic analgesics:
a. Irritation because of the additive action created by rubbing/massage during application
b.More control over application and
dosage form
c. Less GI upset
d.Less interference with warfarin
10.Which of the following is not a counterirritant analgesic?
a. Methyl salicylate
b.Hydrocortisone
c.Camphor
d.Menthol
11.Products that contain methyl salicylate
and trolamine salicylate:
a. Have the potential to cause systemic
reactions, especially after exposure
and exercise
b.Should be used with caution in
patients with aspirin sensitivity or
asthma
c. May cause prolonged prothrombin
time in patients on warfarin
d.All of the above
12.RICE therapy involves all of the following except what?
a. Resting the injured limb for one to
two days
b.Applying ice to the injured limb as
soon as possible and several times a
day for several days to reduce swelling
c. Exercising the injured area to increase
circulation
d.Using compression wraps on the injured area to reduce pain and swelling
13.Which of the following are appropriate treatments for strains and sprains?
a. Massage therapy
b.Thermotherapy
c.Stretching
d.Exercising
14.Which of the statements about cryotherapy and thermotherapy for pain
treatment are false?
a. These therapies have grown in use
and are reflected in increasing sales of
hot/cold packs and wraps
b.They should be applied every two
hours up to four times a day
c. They can be used with other pain
treatments
d.A number of new products designed
to ease use and conform to various areas of the body have been introduced
to the market
15.Which statement regarding therapeutic massage is true?
a. It is considered a complementary, alternative medicine therapy and is not
used for medical treatment per se.
b.It should never be self-administered.
c. There is a growing body of evidence
that it can reduce chronic pain in a
number of conditions.
d.It should be provided only by certified therapists.
july 2015 •
10
Pharmacist CE Lesson
16.Which of the following are considerations when choosing a therapeutic
massage device?
a. The area of the body in pain where
the device will be used and its ease of
use for this area
b.What body areas the device may be
used upon, including any attachments
and its portability
c. Whether the device offers heat and
multiple massage settings
d.All of the above are considerations
17.Regarding cold therapy:
a. It should be applied in 15- to 20-minute intervals for four hours
b.Should not be used for more than 20
11 • july 2015
minutes at a time because excessive
icing can cause vasoconstriction and
reduce clearance of inflammation
from the area
c. May be useful in treating persistent
pain
d.Does not penetrate muscles or joints
18.With regard to headache treatment:
a. Rebound headaches can be caused by
overuse of decongestants
b.Migraine headaches are usually
caused by weather and last several
days
c. Massage therapy has proven moderately effective
d.Thermotherapy is used only after systemic analgesics have failed
19.Which of the following are appropriate conditions for self-treatment of
osteoarthritis?
a. Moderate to severe pain
b.Pain lasting more than two months
after step treatment
c. Pain accompanied by abnormal
movement or deformed limbs
d.Mild joint pain
20.Massage therapy may be useful for all
of the following conditions except:
a. Back pain
b.Neck and shoulder pain
c. Severe dysmenorrhea
d.Certain headache types
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