Pain Management and Pharmacy

This article first appeared in the Australian Journal of Pharmacists (AJP) AJP.com.au[1] on 23APR15 and an abridged version is reproduced here with kind permission

Pain is a universal symptom and yet pharmacists—as the most accessible healthcare providers—can play a vital role in helping patients take action and 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 home medication reviews (HMRs)[2], enhanced self-care support to protect against overuse or misuse of analgesics and Non Steroidal Anti Inflammatory Drugs (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 Pharmaceutical Society of Australia (PSA) Award for Quality Use of Medicines (QUM) in Pain Management[3], says, “The biggest hurdle to improving pain management is changing patients understanding of pain and how it is best managed. Unfortunately everyone believes there is 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[4] 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.

“You can 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.

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.

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 over the counter (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.

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.

United front

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 directly 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.

She 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.

Case study

Olly Zekry, is a clinical consultant pharmacist and winner of the PSA QUM in Pain Management Award 2014.

Zekry 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 a 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 Visual Analogue Scale (VAS) score is 6/10 and her worst VAS score 7/10. The pain is in the lumbar spine and at its worst it radiates in the thigh region. Pain is reduced with bed rest. Her dose of paracetamol/codeine had been at the prescribed maximum (1000/60mg four times daily) for the past two months with no relief.

“When I interviewed Jackie I realised she has two potential red flag indicators; firstly she is aged over 50 and secondly her condition hasn’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.

“In Jackie’s case, her largest issues seem to be about her ability to do things—general activity, work and walking. As conservative analgesic therapy hasn’t enabled Jackie to implement active self-management strategies effectively, the decision is to consider the use of stronger analgesics.

“Jackie’s suitability for an opioid trial is assessed using the Opioid Risk Tool (ORT). She scores 2 points due to her sister’s past use of marijuana. Her score places 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:

1. Cease paracetamol/codeine
2. Start patient on buprenorphine patch 5mcg/ph
3. Continue with heat packs
4. Encourage Jackie to increase her level of physical activity and the frequency of walking from every second day to daily
5. Encourage patient to lose weight.”

“Jackie’s opioid use is monitored by the GP using the ‘5 As’ opioid therapy monitoring tool[5]. After 2 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 is monitored by monthly reviews and her GP will discuss stopping opioid therapy once she has achieved her goals and her physical condition has improved.”

[1] Issued by the Pharmaceutical Society of Australia (PSA)

[2] Pharmacist requires a written referral from the GP to conduct a HMR and after interviewing the patients must prepare a clinical report with their recommendations to the GP. Only pharmacists accredited by the Australian Association of Consultant Pharmacists (AACP) can conduct HMRs.

[3] Sponsored by Mundipharma

[4] Medications review conducted by the pharmacist in the pharmacy without a written referral from or follow up with the GP. Pharmacists are not required to be AACP accredited to conduct Medschecks

[5] 5 A’s opioid therapy monitoring tool:

1. Activity
2. Analgesic
3. Adverse effects
4. Aberrant behaviours
5. Affect