Pharmaceutical Care of people with Chronic Pain

Pharmaceutical Care of people with Chronic Pain Deborah Paton Practice Pharmacist NHS Fife 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 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) Pain Pathway 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 Categorisation of pain Different types of pain Nociceptive descriptors Neuropathic descriptors Cramping, tender Gnawing, heavy Aching Splitting Shooting Hot-burning Sharp Stabbing Acute Pain  Essential biological response to injury  Last a short time <1month  Associated with anxiety and hyperactivity of sympathetic nervous system 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 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 nonmalignant chronic pain.  Only 33% PCOs operate a formal/structured service for chronic pain management in primary care Pain Assessment      Severity Location Duration Intensity Periods of remission and degree of fluctuation  Exacerbating & relieving factors  Response to treatment  Psychological factors  Sociological factors Pain Assessment  Individualised- what does it mean to the patient?  Subjective  Quality of Life- pain diaries  Identify neuropathic elements  Identify safety issues Pain 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 WHO 3 step ladder 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 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 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 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 nonNSAID, in presence of inflammation or if required for long term use add PPIAvoid Cox-IIs plus aspirin negation of GI benefit - this is under review.  Neuropathic pain Adjuvant Analgesics Antidepressants Tricyclic antidepressants  Amitriptyline/ Nortriptyline/ Clomipramine  Unlicensed use  Beneficial in neuropathic „burning‟ pain SSRI  Fluoxetine/ paroxetine  Unlicensed use  Improves mood and increases Serotonin at synapses 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 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 Topical products      Topical NSAIDs v Rubefacients Limited evidence Stimulate A fibres increasing inhibitory response? Counter irritant Topical NSAIDs costly 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 Osteoarthritis       Aim of treatment is pain relief & mobilisation Regular simple analgesics particularly paracetamol NSAIDs-caution in longterm use Intra-articular steroids Weight reduction Joint replacement 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 Rheumatoid Arthritis  Treatment aims:  Pain & inflammation relief  Preserve joint damage  Preserve / improve joint function  Treatment     DMARDs NSAIDs Simple analgesics Systemic steroids 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 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 Self-help  Encourage exercise e.g. Walking and tai chi  Self-help e.g. Pain Association  Acupuncture, acupressure are helpful-TENS machines 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%) 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 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. 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 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 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 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 Thank you