Pharmaceutical Care of people with Chronic Pain

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Pharmaceutical Care of people with Chronic Pain

• Deborah Paton
• Lead Pharmacist Pain Management NHS Fife
• NHS Fife

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Objectives

• 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

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What causes pain?

• 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)

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Pain Pathway
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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

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Categorisation of pain
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Different types of pain
Nociceptive descriptors Neuropathic descriptors
Cramping, tender Shooting
Gnawing, heavy Hot-burning
Aching Sharp
Splitting Stabbing
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Acute Pain

• Essential biological response to injury
• Last a short time lt1month
• Associated with anxiety and hyperactivity of
  sympathetic nervous system

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Chronic Pain

• Pain persisting/recurring for gt3months 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

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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

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Pain Assessment

• Severity
• Location
• Duration
• Intensity
• Periods of remission and degree of fluctuation

• Exacerbating relieving factors
• Response to treatment
• Psychological factors
• Sociological factors

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Pain Assessment

• gt Individualised- what does it mean to the
  patient?
• gt Subjective
• gt Quality of Life- pain diaries
• gt Identify neuropathic elements
• gt Identify safety issues

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Pain Management-Principles of Treatment

• - By the Mouth
• - By the Clock
• - By the Ladder
• - Individualised treatment
• - Patient involvement goal setting gt they
  manage pain not the reverse

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WHO 3 step ladder
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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 gt allows
  flexibility and self management

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NSAIDs

• 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

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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

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NSAIDs vs COX IIs

• gt NSAIDs Cox IIs equally effective
• gt Cox-II better tolerated but not safer (CV risk)
• gt NSAID plus gastro-protectant equally effective
  at reducing ulcers/bleeds
• gt Similar non GI risks risk of PPI increase in
  infection rate?
• gt NSAID plus aspirin-if pain control required
  consider non-NSAID, in presence of inflammation
  or if required for long term use add PPI-
• gt Avoid Cox-IIs plus aspirin negation of GI
  benefit - this is under review.

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Neuropathic painAdjuvant 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

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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

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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

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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

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Osteoarthritis

• Active disease (inflammation), not just wear
  tear
• Degenerative disorder of cartilage and bone
• Age, obesity genetics related
• Affects 50 of population gt60yrs
• - Diagnosed through x-ray or arthroscopy

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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

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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 X-rays
• - Flares relapses

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Rheumatoid Arthritis

• Treatment aims
• Pain inflammation relief
• Preserve joint damage
• Preserve / improve joint function
• Treatment
• DMARDs
• NSAIDs
• Simple analgesics
• Systemic steroids

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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

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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

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Self-help

• Encourage exercise e.g. Walking and tai chi
• Self-help e.g. Pain Association
• Acupuncture, acupressure are helpful-TENS
  machines

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Pharmaceutical Care Model Schemes Chronic Pain
Project n41-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)

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Continued prescribed

• 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

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Continued

• 9 (22) prescribed NSAID reported having an ulcer
  or gastric symptoms, only 5 out of the 9 were
  co-prescribed 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.

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Continued-Care issues

• 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

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Why get involved?

• 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

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Continued Professional DevelopmentgtImplementing
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

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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

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• Thank you