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Tackling long term pain relief

How can pharmacy teams help those suffering from long-term chronic pain conditions?

Some forms of pain are short lived, and customers will be able to deal with them quickly and get on with their lives. But how can pharmacy teams help when pain is longer lasting? 

Everyone experiences pain at some point in their life, to varying degrees. Fortunately, most pain disappears after a few days or weeks, once the underlying cause is resolved. If pain doesn’t go away after more than three months, it is classified as chronic pain. Long-lasting pain like this can cause significant discomfort and distress. 

According to National Institute for Health and Care Excellence (NICE) guidance on chronic pain in the over-16s published in April 2021, chronic pain affects between one third and one half of the UK population. 

Chronic 'secondary' pain is caused by an underlying condition, such as arthritis, a digestive problem or endometriosis. Chronic 'primary' pain, such as fibromyalgia or chronic primary headache, has no clear underlying cause. The prevalence of chronic primary pain is unknown, but NICE estimates it to be between one and six per cent of the English population.

According to the Versus Arthritis report Chronic pain in England: Unseen, unequal, unfair, which was published in June 2021, chronic pain affects 53 per cent of people aged 75 years and older, compared with only 18 per cent of those aged 16 to 34. This is most likely because long-term musculoskeletal conditions such as osteoarthritis tend to affect older people. 

However, more young adults are now reporting high impact chronic pain, possibly because of increased sedentary lifestyles, rising obesity rates or adverse socioeconomic trends over the last decade.

"Social disadvantage, deprivation and psychological stress can increase people’s risk of developing chronic pain in the first place, and some groups are more affected than others," says Dr Benjamin Ellis, senior clinical policy advisor to Versus Arthritis and consultant rheumatologist. "The Chronic pain in England: Unseen, unequal, unfair report found that chronic pain affects nearly twice as many women in the most deprived areas (45 per cent) as men in the least deprived areas (27 per cent)."

Understanding is key

Chronic primary pain, in particular, can be difficult to manage as medical treatments are not always helpful. 

According to the Versus Arthritis report, 5.5 million people in England (12 per cent of the population) have high impact chronic pain, the most disabling form. This means they struggle with everyday activities and taking part in family life and hobbies. Their pain can disrupt sleep and lead to severe fatigue and poor mental health. 

"Unfortunately, people with chronic pain are likely to have recurrent symptoms throughout their lives," says Dr Naomi Newman-Beinart PhD, chartered psychologist and chronic pain expert. "When your brain filters pain signals coming from your body, it’s not just about the feelings of pain – feelings and emotions get involved here too. How you think about your pain can often make it feel worse. This is why people often find that a combination of different approaches might work best to help improve their pain and also their quality of life."

According to Dr Ellis, if someone comes to the pharmacy for support for chronic pain, the first step is to understand what’s causing it. "Ask about their diagnosis," he says. "If they know what it is, then tailor advice using the relevant NICE guideline. 

"For example, people with osteoarthritis may not have tried topical NSAIDs or given capsaicin cream a go. There’s also NICE guidance on rheumatoid arthritis, back pain and chronic primary pain, including conditions such as fibromyalgia. All healthcare professionals should be familiar with these guidelines and take the time to read up on them."

“People often find that a combination of different approaches might work best to help improve their pain”

Management strategies

If a customer’s pain isn’t being well managed, their GP may be able to refer them to a pain management clinic that offers a holistic treatment approach. This may involve medication, counselling, relaxation, electrical stimulation devices, physiotherapy, exercise, dietary changes, acupressure and massage.

"Management of pain is not a simple or one-dimensional process," says Dr Ashish Shetty, pain medicine consultant at the National Hospital for Neurology and Neurosurgery at University College London Hospitals, and NuroKor’s chief medical officer. "Origins and causes of pain are often highly personal to every patient. Pain management clinics provide those affected by chronic pain with an expert-guided service to find solutions that suit their needs and lives best."

The charity Crohn’s & Colitis UK launched its 'Pain Collaborative Network' in 2019, with the aim of improving how pain associated with inflammatory bowel disease is managed as well as the quality of life for people who experience it. "We know pain is a debilitating symptom of Crohn’s and Colitis," says Rachel Ainley, head of research and evidence at Crohn’s & Colitis UK. "This can be constant and relentless, and current treatment options are not good enough. We’re optimistic that the work of the Pain Collaborative Network can drive research into this area."

Pharmacy advice

Since medical treatments for chronic pain are limited, customers may come into the pharmacy for over the counter products and self care advice. 

"People with chronic pain often (quite reasonably) just want something to make their pain go away, or at least to reduce it," says Dr Ellis. "But for many types of chronic pain, pharmacological treatments just don’t help that much with pain itself. We owe it to people with chronic pain to be honest about this. 

"That doesn’t mean there’s nothing that can be done. Far from it. Chronic pain can affect every aspect of a person’s life. People may need support with mental health and sleep, mobility and home aids and adaptations, employment rights and benefit payments."

Of course, regardless of its duration, pain can have many different causes. Let’s take a look at some of the most common causes of long-term pain.

Common causes of long-term pain

Osteoarthritis is the most widespread form of arthritis in the UK. It most commonly affects the knees and hips, as well as the small joints in the hands. 

The condition occurs when cartilage protecting the ends of the bones breaks down, causing pain and stiffness when moving the joint. The exact reason why osteoarthritis occurs is unknown, but risk factors include getting older, a previous joint injury and family history.

According to NICE guidance on osteoarthritis, last updated in December 2020, paracetamol may help to ease pain, along with transcutaneous electrical nerve stimulation (TENS) and topical NSAIDs and capsaicin (for knee or hand pain). However, NICE adds that exercise should be a core treatment, especially in warm water. Versus Arthritis recommends consulting a physiotherapist, osteopath or chiropractor, and says that using a heat pad or a hot water bottle and/or an ice pack or a cold water compress may also help.

"Treatment guidelines followed by doctors in the UK recommend that people with arthritis are advised to maintain a healthy weight and keep physically active, while strengthening their muscles and protecting any damaged joints during daily activities," says Dr Rod Hughes, a consultant rheumatologist based in Surrey. "Pharmacies can play a pivotal role in steering people with joint pain towards a prevention programme, promoting lifestyle and diet changes, including recommendation of clinically proven joint-specific supplements, such as galactolipid (or GOPO for short)."

According to NICE guidance on lower back pain, which was updated in December 2020, exercise programmes may help to ease pain and get people moving again. 

Exercise can be used alongside manual therapies such as massage and/or psychological therapies such as cognitive behavioural therapy (CBT). Oral NSAIDs may also help, if these are suitable for the customer.

A form of exercise known as the Alexander Technique may improve back pain that has been caused by poor posture. A survey of 1,000 Brits conducted by Perspectus Global in winter 2021/2022 revealed that nearly three in 10 people know their posture is causing them pain and this has been aggravated by poorly arranged work-from-home spaces during the pandemic. The survey found that 47 per cent of people take painkillers when they get back pain, 40 per cent put their feet up, 28 per cent reach for stretching exercises and 28 per cent soothe themselves with a warm bath.

"Too many of us are still making do with a sofa or –worse still – a bed as our workspace, which plays absolute havoc with posture and spine health," says Sammy Margo, physiotherapist and advisor to Deep Heat. 

"Poor posture is a well known consequence of sitting for long periods of time, and the end result is often a painful, stiff back. This requires a multi-modal approach, which includes immediate pain relief and muscle relaxation, alongside strategies to remobilise and reduce the risk of ongoing issues."

According to NICE guidance on headaches, which was updated in December 2021, tension-type headaches and migraine are considered to be chronic if they occur on 15 or more days a month for more than three months. 

Tension-type headaches tend to occur on one side of the head and feel like a pressing/tightening pain, whereas migraine can occur on one or both sides, causing a pulsating pain. Tension-type headaches aren’t aggravated by activity, but migraine usually is. Migraine can also cause unusual sensitivity to light and/or sound, as well as nausea and/or vomiting. Some people get migraine with aura (with or without a headache), with visual and sensory symptoms (e.g. flickering lights, numbness, pins and needles) lasting for five to 60 minutes before a migraine attack.

Mark Hopkins, registered pharmacist at Hopwoods Pharmacy in Cardiff, Wales, says that using over the counter bioelectronics devices on the base of the neck can significantly ease pain and release muscle stiffness and spasm. "Customers should keep a diary to identify key triggers, including food, environmental, hormonal and lifestyle factors," he says. "Applying ice caps and cold strips/gels to the forehead can help in preventing migraine and/or cluster headaches from getting progressively worse. Applying heat or wheat packs to the shoulders and neck can reduce muscle tension and increase blood circulation."

According to Versus Arthritis, fibromyalgia affects between 1.8 million and 2.9 million people in the UK, usually developing between the ages of 25 and 55. It is thought to be caused by a problem with the nervous system that affects how well it processes pain from other parts of the body. Fibromyalgia may be triggered by an infection, an accident or extreme stress or anxiety.

Fibromyalgia causes a wide range of symptoms, affecting all parts of the body. These include pain and stiffness (especially in the neck and back), sore muscles (causing a bruised feeling), fatigue, poor sleep, poor concentration, headaches, irritability and low mood, irritable bowel/bladder syndrome, painful sex, and increased sensitivity to temperature and noise. 

According to NICE guidance on chronic primary pain, people with fibromyalgia shouldn’t take NSAIDs or paracetamol on an ongoing basis. Instead, they should be encouraged to remain as physically active as possible and try psychological therapies, such as acceptance and commitment therapy or CBT. Acupuncture or dry needling delivered by a suitably qualified healthcare professional may help. Low-dose antidepressants (e.g. amitriptyline) may help to improve quality of life, pain, sleep and mood, even without a diagnosis of depression. However, many doctors will only prescribe medicines once the patient has tried the other options first.

"No two patients with fibromyalgia are the same, and often there are vast differences in symptoms and the site of pain," says Mark Hopkins. "Gentle exercise such as yoga, Pilates and walking may help, as well as psychological support (online, in person or app-based cognitive behavioural therapy and meditation). Over the counter pain relief can be provided with caution, depending on other prescribed pain relief and medications, as well as over the counter bioelectronic devices over pain sites to reduce pain and improve mobility."

According to the charity Guts UK, around a third of the UK population experience symptoms of irritable bowel syndrome (IBS). 

NICE guidance on the condition, which was last updated in 2017, states that the IBS is only diagnosed if someone has tummy pain or discomfort that is relieved by defaecation and is associated with constipation, diarrhoea or both, as well as bloating and passing mucus. 

Symptoms are often made worse by eating, and may also include lethargy, nausea, backache and bladder symptoms. IBS symptoms may be eased by:

  • Taking antispasmodic medicines such as mebeverine or peppermint oil
  • Relaxation exercises, counselling and CBT to reduce stress
  • Avoiding specific food triggers, adjusting fibre intake and avoiding sorbitol (which can worsen diarrhoea)
  • Eating regular meals and not rushing when eating
  • Drinking at least eight cups of fluid a day, including water and herbal teas
  • Restricting tea, coffee, alcohol and fizzy drinks
  • Eating oats and linseeds to ease wind and bloating
  • Trying probiotics for at least four weeks
  • Using laxatives for constipation (but not lactulose) or loperamide for diarrhoea.

If lifestyle changes and over the counter medicines don’t work, a doctor may prescribe a low dose tricyclic antidepressant.

Learn more about pain

The charity Pain Concern produces leaflets on chronic pain management, as well as a podcast and a quarterly Pain Matters magazine for people living with chronic pain. These may be useful learning resources for the community pharmacy team. 

For information on specific types of chronic pain, you can contact national charities such as:

Pharmacist Mark Hopkins from Cardiff has supported and launched a growing network of more than 20 community pharmacy-led pain clinics across the UK. "The ‘Change Grow Live – Dependence Forming Medications’ team support those who are prescribed strong painkillers and would like help in reducing their use," he says. "Liaise with local GPs, orthopaedics, chiropractic consultants and physios. Many primary and secondary care services provide local training courses and resources to support pain management, and CPPE offers an online training and educational course on pain management to contribute to improving patient care."

You can contact the Change Grow Live – Dependence Forming Medications team on email at first.steps@cgl.org.uk 

For more on CPPE programmes.

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