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Playing the long pain

From advice and signposting, to lending a sympathetic ear, there is plenty that pharmacy teams can do to support customers living with chronic pain.

It is thought that between a third and half of UK adults (just under 28 million of us) are affected by chronic pain.

Statistics indicate that women (38 per cent) are more affected than men (30 per cent) and unsurprisingly, prevalence increases with age, ranging from 16 per cent among people aged 16-24 to 53 per cent among those aged 75 years and older. 

Since the three most common types of pain are back pain (reported by 53 per cent of people), headache (48 per cent), and joint pain (46 per cent), it’s likely that pharmacy teams will have daily interactions with customers experiencing chronic pain – so what exactly is it, why does it happen, and what can help?

The cause

Pain is deemed to be chronic when it persists or recurs for more than three months and is an unpleasant sensory and emotional experience associated with “actual or potential tissue damage”, according to the National Institute of Health and Care Excellence (NICE). Chronic primary pain persists for longer than three months and is associated with significant emotional distress or functional disability that cannot be explained by another chronic condition.

Chronic pain is “multifactorial” – meaning that biological, psychological, and social factors contribute to the pain syndrome – and there are many possible causes, such as an acute injury like a fracture; surgery or medical interventions; an ongoing degenerative illness or musculoskeletal condition such as osteoarthritis, rheumatoid arthritis or ankylosing spondylitis; conditions such as cancer, angina, irritable bowel syndrome (IBS) or chronic obstructive pulmonary disease (COPD); as well as headache from medicines overuse, or migraine; and even psychological causes, including anxiety, depression and sleep disturbances.

Treatment options

Although analgesics can sometimes work effectively to relieve chronic pain, data from NICE says this is only achieved in a small percentage of people, and it is unusual for any analgesic, including strong pain relief such as opioids, to completely eliminate chronic pain.

As a result, non-pharmacological treatment may be more effective at reducing symptoms and disability in some people experiencing chronic pain and can also augment and complement analgesic use. 

NICE recommends that everyone with chronic primary pain is encouraged to remain physically active for longer-term general health benefits, so pharmacy teams can recommend people ask their GP – or local social prescriber – for a referral to a supervised group exercise programme, as well as referral to a specialist pain centre if appropriate.

Acceptance and commitment therapy (ACT) or cognitive behavioural therapy (CBT) can also help, and the person’s GP will also be able to talk them through the benefits and risks of considering an antidepressant – either amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine, or sertraline for people aged 18 years and over – as these may be used off-label to help with quality of life, pain, sleep, and psychological distress, even in the absence of a diagnosis of depression.

Although not recommended for chronic pain, there are some useful gadgets out there which may provide relief from acute pain, as well as recovery from sporting injuries.

Turning to gadgets

Transcutaneous electrical nerve stimulation (TENS) is a method of pain relief involving the use of a mild electrical current from a small device via electrode pads that stick to the skin. The electrical impulses can reduce the pain signals going to the spinal cord and brain, which may help relieve pain and relax muscles. They may also stimulate the production of endorphins, which are the body’s natural painkillers.

While NHS advice is that there is not yet enough “good-quality scientific evidence to say for sure whether TENS is a reliable method of pain relief”, some healthcare professionals believe it seems to help some people, although how well it works depends on the individual and the condition being treated.

Some pharmacies stock TENS machines – which range in price from £20 to £100 – but people should be advised to ask their GP about a referral to a physiotherapist or pain clinic first to find out whether a TENS machine is appropriate and be taught how to use it properly.

NuroKor’s patented bioelectronic devices offer another drug-free solution for the management of pain, physical recovery and enhanced athletic performance by directly targeting the body’s peripheral nervous system. 

They use “microcurrents” to deliver pain relief and promote recovery by managing the pain signals that the nerve endings are sending to the brain, as well as work at the cellular level to reduce inflammation in the tissue.

Used by Olympic and international athletes to manage their physical recovery from sessions and improve muscle function, speed and endurance, the company is currently focusing on tailoring its device to treat female pain conditions including period pain, endometriosis and fibromyalgia.

Massage guns – also known as muscle guns – are electronic massage devices offering varying levels of intensity designed to target different muscle groups to strengthen and regenerate muscles and relieve tension. 

There are lots of different brands, including those from German manufacturer Beurer – which recommends using a muscle gun during a warm-up to activate muscles, as well as post-workout to help muscles relax, reduce delayed onset muscle soreness (DOMS) and stiffness and promote speedier muscle recovery. Other benefits may include increased blood circulation to muscles and, according to Beurer, “faster healing of atrophied muscles”.

Case study

Kelly Louise Preece, 36, works at a university in the South West of England. She is living with chronic pain from osteoarthritis, fibromyalgia and endometriosis

“I was diagnosed with osteoarthritis in my early 20s, then fibromyalgia (FM) in 2017, and endometriosis a few years later. The main places I experience pain are in my fingers, knees, and joints at the base of my big toes, and some in my ankles and hips. My pain levels are hugely variable but tend to be linked to activity, so if I do something strenuous, I know that will set off certain levels of pain later that day. Stress, anxiety and lack of sleep also affect my pain levels. 

“If I have a flare up there are lots of things I can do. I am on the base dose of gabapentin, which is 300mg three times a day, but my prescription says if my pain is bad I can take 600mg once or twice a day for a couple of days, and although that doesn’t get rid of the pain it makes it much less debilitating. Hot baths, electric blankets and hot water bottles all help while you are using them, and I’ve been taking CBD for a while when things are bad, which makes the pain a lot more manageable and means I can do basic stuff like shower, eat and work (I mainly work from home).

“I’ve found you have to become an expert patient about your own pain, and I do a lot of my own research. For example, there is some evidence an anti-inflammatory diet can have a huge impact on FM symptoms, so I have started seeing a dietician for more advice. 

“I collect my prescriptions every month and although the pharmacy I use is lovely no one has ever talked to me about my chronic pain or signposted me on to any other services, so if a pharmacist or staff opened up the conversation it would be brilliant, and I’m sure these conversations could have saved years of research that I’ve had to do myself.”

Looking at self care 

Although it’s a difficult topic to address, pharmacy teams are also ideally placed to tactfully and sensitively discuss with patients that their symptoms will fluctuate over time and that they may have flare-ups with no obvious trigger. There is also the possibility that the pain may not improve or may get worse and need ongoing management.

However, it is also possible for people to experience improved quality of life, even if their pain remains unchanged, and this is where self-care advice can prove really valuable. For example, pharmacy teams can signpost people to self-help resources identified and recommended by local pain services, as well as online materials such as the British Pain Society’s (BPS) leaflet Understanding and managing long-term pain, and the websites Pain Tool Kit, and Arthritis Care at: britishpainsociety.org.

Of course, community pharmacies are experienced in giving advice and support about diet, weight, alcohol use, smoking, and exercise – all of which can be useful adjuncts for people living with chronic pain.

There can be a stigma around chronic pain, with those who don’t understand or have never experienced it wondering if sufferers are ‘putting it on’ – especially as in many cases the causes are not visible, so pharmacy staff can also help people living with chronic pain by giving them the compassion and attention they need and deserve.

Red flags

The level of pain

Pharmacy staff should be aware of the level of pain customers are experiencing and refer to a pharmacist where necessary. This is also useful when determining what type of pain relief should be recommended to ensure patients receive the correct care and treatment, and whether a referral to their GP will be required.

The location of the pain

For example, pain within the thorax could indicate a gastric or duodenal ulcer, whilst pain within the chest could indicate a more serious condition, such as a heart attack. This information is key in helping pharmacy teams to understand what the best course of action is.

The cause of the pain

If it is a physical injury, such as open wounds or broken bones, the customer may require an assessment or referral to their GP.

The duration of the pain

It is important for pharmacy teams to assess if the pain has been being experienced for a long time. Notably, it is useful to know if the pain is a long-term condition that is being treated by the patient’s doctor. This will determine if the existing treatment is suitable or whether a different product is required.

The timing of the pain

Pain that persists through the night, wakes the patient and is unrelenting even with pain relief, could indicate that the customer has a tumour. As such, this is a symptom that pharmacy teams should be on high alert for and ready to refer patients to their GP where required.

Existing medical conditions and prescriptions or medications

Pharmacy teams should be aware of other medication that customers may be taking to ascertain whether they already contain pain relief, such as paracetamol. What’s more, some pain relief medication may not be suitable for patients with existing conditions, for example, Ibuprofen can negatively affect breathing in asthmatics. 

The following types of pain are unusual and once pharmacy teams are made aware of them, they should refer the patient to the pharmacist for assessment:

  • Severe pain: If the patient is experiencing severe pain or seems to be in distress from their pain, pharmacy teams should always refer them to the pharmacist for further assessment
  • Chest pain: This could be indicative of a more serious condition such as a heart attack and may need urgent care
  • Bleeding or injury with pain: Depending on the type of injury, the pharmacist may decide that the patient needs to be referred to their GP rather than taking pain relief
  • Pain causing difficulty in breathing: The pharmacist will need to assess the patient and determine the best course of action for them
  • Neck pain or stiffness: Pharmacists will need to find the cause of the pain and see if a referral is required, as neck pain can indicate meningitis in some instances
  • Pain causing loss of physical function: Any loss of movement due to pain should be assessed by the pharmacist to see if a referral is required
  • Any visual disturbance or photosensitivity associated with the pain: Any pain that influences a patient’s eyesight should be referred to the pharmacist as soon as possible to avoid the possibility of long-term damage
  • Fever: A fever could indicate an infection of some kind, so the patient may need further assessment and treatment, which should be reviewed on a case-by-case basis. 

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