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Pharmacy Pharmaceutical Care of people with Chronic Pain Deborah Paton Lead Pharmacist Pain Management NHS Fife NHS Fife Quality Education for a Healthier Scotland Objectives Pharmacy • To provide an overview of the aetiology and therapeutic management of chronic pain • Identify the key pharmaceutical care issues of people with chronic pain • Explore ways of positively impacting on the care of this patient group Quality Education for a Healthier Scotland What causes pain? Pharmacy Trauma/ injury initiates immediate nerve impulses to brain Injury to cells result in chemical release H+ K+ Substance P Bradykinin 5HT Phospholipids Prostaglandins Blood vessels leak resulting in inflammation Stimulate C-fibres (slow response) Quality Education for a Healthier Scotland Pain Pathway Pharmacy Quality Education for a Healthier Scotland Nerve Fibres ( A delta) Myelinated Fast conductors Gentle pressure and pain (A beta) Thinner – but still myelinated Fast conductors Heavy pressure &temp C - very thin Slow conductors PAIN, Pressure, temp & chemicals Quality Education for a Healthier Scotland Pharmacy Categorisation of pain Pharmacy Quality Education for a Healthier Scotland Different types of pain Nociceptive descriptors Neuropathic descriptors Cramping, tender Shooting Gnawing, heavy Hot-burning Aching Sharp Splitting Stabbing Quality Education for a Healthier Scotland Pharmacy Acute Pain Essential biological response to injury Last a short time <1month Associated with anxiety and hyperactivity of sympathetic nervous system Quality Education for a Healthier Scotland Pharmacy Chronic Pain Pain persisting/recurring for >3months after acute injury Associated with changes in structure and operation of central nervous system Cognitive control-behavioural models important Pain assessment is essential component of management Quality Education for a Healthier Scotland Pharmacy Chronic Pain in Scotland (2004 Foster Project) Prevalence of 18% of the population How many patients do you see as a pharmacist with chronic pain? What medications have been “tried out” with these patients Few Primary Care Organisation (PCOs) provide guidance for medication & management of non-malignant chronic pain. Only 33% PCOs operate a formal/structured service for chronic pain management in primary care Quality Education for a Healthier Scotland Pharmacy Pain Assessment Severity Location Duration Intensity Periods of remission and degree of fluctuation Pharmacy Exacerbating & relieving factors Response to treatment Psychological factors Sociological factors Quality Education for a Healthier Scotland Pain Assessment > Individualised- what does it mean to the patient? > Subjective > Quality of Life- pain diaries > Identify neuropathic elements > Identify safety issues Quality Education for a Healthier Scotland Pharmacy Pain Management-Principles of Treatment Pharmacy - By the Mouth - By the Clock - By the Ladder - Individualised treatment - Patient involvement & goal setting > they manage pain not the reverse Quality Education for a Healthier Scotland WHO 3 step ladder Quality Education for a Healthier Scotland Pharmacy Analgesic medication key points * Paracetamol round the clock & explore and dispel fears of safety or ineffectiveness * Codeine-15% unable to metabolise - add in doses of 30 mg codeine or 30mg dihydrocodeine if necessary – using lower doses not supported by evidence. * Note need for laxative at therapeutic doses of opioids * Separate agents are recommended > allows flexibility and self management Quality Education for a Healthier Scotland Pharmacy NSAIDs Pharmacy NSAIDs always consider is there an active indication e.g. is inflammation present in OA? Full inflammatory effect can take 2-4 weeks & 60% will benefit from first choice-has there been an appropriate trial? Lowest effective dose in pulse or prn basis where possible Is there a risk of GI bleed? If yes review continued need and consider gastroprotectant Quality Education for a Healthier Scotland NSAIDs Risks - Over 20% of drug related hospital admissions are due to NSAIDs - Absolute risk: over 65 years, previous GI bleed, previous peptic ulcer-aide memoir - Risk with increasing dose, type and duration of therapy, age, concurrent medication and co-morbidities - 50-60% of people who will have GI bleed are asymptomatic before presentation Quality Education for a Healthier Scotland Pharmacy NSAIDs vs COX IIs > NSAIDs & Cox IIs equally effective > Cox-II better tolerated but not safer (CV risk) > NSAID plus gastro-protectant equally effective at reducing ulcers/bleeds > Similar non GI risks – risk of PPI increase in infection rate? > NSAID plus aspirin-if pain control required consider non-NSAID, in presence of inflammation or if required for long term use add PPI> Avoid Cox-IIs plus aspirin negation of GI benefit - this is under review. Quality Education for a Healthier Scotland Pharmacy Neuropathic pain Adjuvant Analgesics Antidepressants Tricyclic antidepressants Amitriptyline/ Nortriptyline/ Clomipramine Unlicensed use Beneficial in neuropathic ‘burning’ pain SNRI Duloxetine/ Venlafaxine Unlicensed use Improves mood and increases Serotonin& Noradrenaline at synapses SSRI- no real evidence Fluoxetine/ paroxetine Unlicensed use Improves mood and increases Serotonin at synapses Quality Education for a Healthier Scotland Pharmacy Adjuvant Analgesics Anticonvulsants • Carbamazepine & Valproate useful in ‘shooting pain’ indications (e.g. trigeminal neuralgia) • Gabapentin / Pregabalin - Acts centrally, GABA analogue - Slow titration, particularly in elderly Quality Education for a Healthier Scotland Pharmacy Adjuvant Analgesics Corticosteroids Prednisolone & dexamethasone Used to control inflammation where NSAIDs insufficient e.g. Rheumatoid conditions Intra-articular route may give relief for a few months Quality Education for a Healthier Scotland Pharmacy Topical products -Topical NSAIDs v Rubefacients was previously contentious - Some evidence to suggest Topical NSAIDs useful in small joint inflammation - Stimulate A fibres increasing inhibitory response? - Counter irritant - Capsaicin, derived from chilli peppers useful in diabetic neuropathy and OA Quality Education for a Healthier Scotland Pharmacy Osteoarthritis -Active disease (inflammation), not just wear & tear -Degenerative disorder of cartilage and bone -Age, obesity & genetics related -Affects 50% of population >60yrs - Diagnosed through x-ray or arthroscopy Quality Education for a Healthier Scotland Pharmacy Osteoarthritis - Aim of treatment is pain relief & mobilisation - Regular simple analgesics particularly paracetamol - NSAIDs-caution in long-term use - Intra-articular steroids - Weight reduction - Joint replacement Quality Education for a Healthier Scotland Pharmacy Rheumatoid Arthritis - Chronic disabling systemic disease - Often affects symmetrical peripheral joints - Can affect all ages - Auto-immune disease - Diagnosed through symptoms, blood tests (ESR,RF,CRP) and Xrays - Flares & relapses Quality Education for a Healthier Scotland Pharmacy Rheumatoid Arthritis Treatment aims: Pain & inflammation relief Preserve joint damage Preserve / improve joint function Treatment DMARDs NSAIDs Simple analgesics Systemic steroids Quality Education for a Healthier Scotland Pharmacy Pharmaceutical care issues – Understanding and compliance are they taking it if not why not? Fear of hidden long term risk Fear of becoming immune to effects over time Fear of addiction Previous experience of ADR or sub-optimal therapy Patient beliefs Misunderstanding of benefits or how medication works Quality Education for a Healthier Scotland Pharmacy Effectiveness and safety - Use of Pain diaries and pain scores - Optimising timing frequency and dose - Identifying undiagnosed neuropathic element - Activities and time when pain is worse - History of ulcer or gastric bleed - Reviewing continued need for NSAID - Co-morbidity-CVD, hypertension - Confirm co-prescribing or buying of medications that may increase risk - Enquire if they are experiencing side-effects Quality Education for a Healthier Scotland Pharmacy Self-help Pharmacy Encourage exercise e.g. Walking and tai chi Self-help e.g. Pain Association Acupuncture, acupressure are helpful-TENS machines Quality Education for a Healthier Scotland Pharmaceutical Care Model Schemes Chronic Pain Project n=41-medication NSAID 26 (63%) Cox 11 3 (7%) Paracetamol 7 (17%) !!!! Co-codamol 18 (44%) Co-dydramol 5 (12%) Strong opioid 14 (34%) Neuropathic 9 (22%) Quality Education for a Healthier Scotland Pharmacy Continued prescribed Pharmacy 73% had pain for more than 5 years 7(17%) used neuropathic pain descriptors but were not prescribed medication to manage this 16 (44%) described their pain as severe and often or continuous 14 (34%) were purchasing OTC painkillers Quality Education for a Healthier Scotland Continued Pharmacy 9 (22%) prescribed NSAID reported having an ulcer or gastric symptoms, only 5 out of the 9 were coprescribed a gastro-protectant 25 (61%) reported side-effects,mainly constipation and GI 11 referrals were made and 7 referrals were taken forward-unclear if people at GI risk or experiencing neuropathic pain were referred. Quality Education for a Healthier Scotland Continued-Care issues Pharmacy 10 (24%) understanding of medication-fear of adverse effects or taking combining pain killers 15 (37%) optimising dose, frequency or timing of analgesia-before activity etc 2 (5%) reducing risk advising not to take OTC purchases or person taking excessive amounts 8 (20%) advised use of pain diary and follow up Quality Education for a Healthier Scotland Why get involved? Pharmacy Out of the six PCMS Chronic condition projects this group were most supportive of the pharmacists current role and wanted more help-they highlighted; * Friendly and give good advice- side effects * Provide good information and explain dosage * Better than some GPs * Would like more monitoring and follow up along with GPs-as they see pharmacist more often Quality Education for a Healthier Scotland Continued Professional Development>Implementing the Pharmaceutical Care Needs Assessment Chronic Pain Who will you target? - Compound analgesics - People unsatisfied with their pain control - People over 65 on NSAIDs, with or without gastro-protection - Cardiovascular patient on COX-II/NSAID - Anyone that comes in during a quiet moment - 19 patients involved in focus groups completed the PCNA on their own within 10 minutes-this can be done while they are waiting for prescriptions Quality Education for a Healthier Scotland Pharmacy Continued Professional Development - Plan and record - What did you learn tonight-what are the gaps? - How will you meet the gaps? - What is happening locally in relation to effective pain management? - How and when will you find out? - Ideal therapeutic area for pharmacist prescribing Quality Education for a Healthier Scotland Pharmacy Pharmacy Thank you Quality Education for a Healthier Scotland