Quality Education for a Healthier Scotland Pharmacy 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


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


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)


Pharmacy

Pain Pathway


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


Pharmacy

Categorisation of pain


PharmacyDifferent types of pain

Nociceptive descriptors Neuropathic descriptors

Cramping, tender Shooting

Gnawing, heavy Hot-burning

Aching Sharp

Splitting Stabbing


PharmacyAcute Pain

Essential biological response to injury

Last a short time <1month

Associated with anxiety and hyperactivity of sympathetic nervous system


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


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


PharmacyPain Assessment

Severity

Location

Duration

Intensity

Periods of remission and degree of fluctuation

Exacerbating & relieving factors

Response to treatment

Psychological factors

Sociological factors


PharmacyPain Assessment

> Individualised- what does it mean to the patient?

> Subjective

> Quality of Life- pain diaries

> Identify neuropathic elements

> Identify safety issues


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


PharmacyWHO 3 step ladder


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


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


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


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.


Pharmacy

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


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


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


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


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


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


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


PharmacyRheumatoid Arthritis

Treatment aims:

Pain & inflammation relief

Preserve joint damage

Preserve / improve joint function

Treatment

DMARDs

NSAIDs

Simple analgesics

Systemic steroids


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


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


PharmacySelf-help

Encourage exercise e.g. Walking and tai chi

Self-help e.g. Pain Association

Acupuncture, acupressure are helpful-TENS machines


Pharmacy

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%)


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


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.


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


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


Pharmacy

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


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


Pharmacy

Thank you

Quality Education for a Healthier Scotland Pharmacy Pharmaceutical Care of people with Chronic Pain...

Documents

Transcript of Quality Education for a Healthier Scotland Pharmacy Pharmaceutical Care of people with Chronic Pain...