Emma Davies
I’VE worked as a pain specialist pharmacist for 11 years; 10 of them exclusively within pain management. Principally, I am a chronic, non-cancer pain specialist, although I worked in acute pain management in hospital settings for more than seven years as well.
Pain management is perhaps an odd ‘specialty’. Pain of all sorts is omnipresent in society nowadays. It is the most prevalent, symptomatic long-term condition affecting as much as 50% of the population every day. However, Scotland is the only country in Great Britain, which included pain within the recently published Royal Pharmaceutical Society (RPS) long-term condition documents.
One of the issues with pain is that in so many ways, it is familiar. We all experience it at some time whether acutely, following surgery or trauma, sports injuries, childbirth, or due to longer-term problems like arthritis, diabetes or the leading chronic pain cause of ‘bad back’.
In fact, there is not an area of medicine that does not encounter pain. In primary care, pain alone accounts for more than 1 in 5 appointments, and pain is a presenting symptom in more than 90% of hospital admissions. There are no clearly defined figures for the number of community pharmacy encounters that are around pain and analgesia but I strongly suspect it is ‘lots’.
Do we need pain specialist pharmacists? As we are all so accustomed to it — aren’t we all pain specialists in a way? We are used to seeing analgesics being prescribed; we might have a vague idea about the biopsychosocial model of pain or might have had some involvement with a pain team. We might be able to explain how different analgesic medicines work. Does this make us knowledgeable about pain management? What is pain management anyway?
Painful truth
The first thing to realise that not all pain is the same and not all pain responds to all analgesics. Research has developed our understanding significantly in terms of the differences between different types of pain — even under the umbrella term of ‘chronic or persistent pain’. So, in order to understand pain, you need, like with any other condition, to understand its pathophysiology.
Once we have that under our belt, we naturally turn to medication – we are pharmacy afterall. Pharmacists all cover analgesics to some extent during undergraduate teaching – how they work, side effects – all bread and butter stuff to medication experts.
However, in chronic non-cancer pain, the evidence to support the use of various analgesic medicines is lacking. We are increasingly aware that medicines only have meaningful effect in a minority of patients. A lot of the drugs that we have used for years to manage pain have evidence to suggest they are also harmful, particularly in the longer-term. So, to show my age, I will quote the Verve “the drugs don’t work, they just make things worse”…for some people.
Now, the biopsychosocial model – this is how we describe the complex interplay between physical changes that may cause pain and the psychological response, which may make ‘treating’ it more difficult. I think lots of people are aware for example, that having low mood makes pain perception worse: for example, you might report higher pain levels when under stress than when relaxed and distracted.
This doesn’t mean, however, that pain is in the person’s head or that antidepressants will sort them out. It isn’t even just that – social circumstances, isolation, relationship breakdown, not feeling believed all impact on a person’s ability to manage pain. Often, the reporting of pain is a manifestation of emotional distress rather than a physical symptom alone. Amateur psychologists abound – it can be barn-door obvious what is going on, but very often, changes in behaviour and presentation are subtle and only become apparent over time.
The drugs don’t always work
Pain management these days is less about drugs and injections and more about supporting self-management. Educating and supporting people to manage their pain and improve their quality of life. This can be time-consuming, hard work. It works against a lot of people’s perception of what medicine should be offering them – which is a cure, a total cessation of pain.
However, 5 minutes spent explaining what pain is, or why it might be persisting is time well spent. Ten minutes talking someone through the PainToolkit leaflet and helping them recognise how pain might be impacting on their life, is five minutes of supported self-management. Undertaking an MUR and advising on judicious use of medication and adding in some exercise advice is supporting someone towards increasing activity, and perhaps eventually realizing that activity is not the cause of the pain; the pain is the cause of the pain.
Educational self-management is not always that easy to come by however. Some pain services are skilled at delivering the approach and engaging people living with pain in the concept and then supporting them in making changes to thinking and doing. Others not so much.
Only around 200,000 people make it to a specialist service each year and when the pain population is estimated to be around 28 million; it’s clear the majority of people with pain are going to be asking their GP or local pharmacist for advice, if anything at all.
Even when people make it to a pain service, it is often after all other options have been exhausted. They’ve been within a medical system, looking for answers and the elusive cure possibly for years. The self-management, de-medicalising approach to pain at that time is like the proverbial slap in the face. “What? That’s it? I’ve waited all this time and now you tell me I have to do it all myself? You really haven’t got any tablets that will get rid of this pain?”
Pharmacy input
Pharmacy staff in all sectors have great potential to become effective pain management supporters. We are trusted professionals, even if we don’t always get the recognition we should for the clinical knowledge and skills we possess.
We are medicines experts. For many people, medicines are pain management and so it should be our job to advise on how medicines fit into a multi-modal approach to managing pain. We have the skills, we have the positioning across the borders of healthcare. Let’s manage pain better. Let’s make pharmacy the pain management specialist.
Emma is PHD student at Swansea University and pharmacist pain practitioner
Read more about Emma here