Pharmaceutical Care of People with Chronic Pain
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Transcript of Pharmaceutical Care of People with Chronic Pain
Quality Education for a Healthier Scotland
Pharmacy
Pharmaceutical Care of people with Chronic Pain
Deborah Paton
Lead Pharmacist Pain Management NHS Fife
NHS Fife
Quality Education for a Healthier Scotland
PharmacyObjectives
• 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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PharmacyWhat causes pain?
Trauma/ injury initiates immediate nerve impulses to brain
Injury to cells result in chemical releaseH+
K+
Substance PBradykinin5HTPhospholipids Prostaglandins
Blood vessels leak resulting in inflammation
Stimulate C-fibres (slow response)
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Pain Pathway
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PharmacyNerve Fibres
( A delta)MyelinatedFast conductorsGentle pressure and pain
(A beta)Thinner – but still myelinatedFast conductorsHeavy pressure &temp
C - very thinSlow conductorsPAIN, Pressure, temp & chemicals
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Categorisation of pain
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PharmacyDifferent types of pain
Nociceptive descriptors Neuropathic descriptors
Cramping, tender Shooting
Gnawing, heavy Hot-burning
Aching Sharp
Splitting Stabbing
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PharmacyAcute Pain
Essential biological response to injury
Last a short time <1month
Associated with anxiety and hyperactivity of sympathetic nervous system
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PharmacyChronic 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
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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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PharmacyPain 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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PharmacyPain Assessment
> Individualised- what does it mean to the patient?
> Subjective
> Quality of Life- pain diaries
> Identify neuropathic elements
> Identify safety issues
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PharmacyPain Management-Principles of Treatment
- By the Mouth
- By the Clock
- By the Ladder
- Individualised treatment
- Patient involvement & goal setting > they manage pain not the reverse
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PharmacyWHO 3 step ladder
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PharmacyAnalgesic 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
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PharmacyNSAIDs
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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PharmacyNSAIDs 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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PharmacyNSAIDs 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.
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Neuropathic painAdjuvant Analgesics Antidepressants
Tricyclic antidepressantsAmitriptyline/ Nortriptyline/ ClomipramineUnlicensed useBeneficial in neuropathic ‘burning’ pain
SNRI Duloxetine/ VenlafaxineUnlicensed useImproves mood and increases Serotonin& Noradrenaline at
synapses
SSRI- no real evidenceFluoxetine/ paroxetineUnlicensed useImproves mood and increases Serotonin at synapses
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PharmacyAdjuvant 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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PharmacyAdjuvant 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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PharmacyTopical 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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PharmacyOsteoarthritis
-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
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PharmacyOsteoarthritis
- 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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PharmacyRheumatoid 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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PharmacyRheumatoid 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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PharmacyEffectiveness 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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PharmacySelf-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 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%)
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PharmacyContinued 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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PharmacyContinued
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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PharmacyContinued-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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PharmacyWhy 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 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
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PharmacyContinued 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