Transcript Palliative Care

Pharmacy
Pharmaceutical Care of people with
Chronic Pain
Deborah Paton
Lead Pharmacist Pain Management NHS Fife
NHS Fife
Quality Education for a Healthier Scotland
Objectives
Pharmacy
• 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
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What causes pain?
Pharmacy
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)
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Pain Pathway
Pharmacy
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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
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Categorisation of pain
Pharmacy
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Different types of pain
Nociceptive descriptors
Neuropathic descriptors
Cramping, tender
Shooting
Gnawing, heavy
Hot-burning
Aching
Sharp
Splitting
Stabbing
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Acute Pain
Essential biological response to injury
Last a short time <1month
Associated with anxiety and hyperactivity of
sympathetic nervous system
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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
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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
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Pain Assessment
Severity
Location
Duration
Intensity
Periods of remission and
degree of fluctuation
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Exacerbating & relieving factors
Response to treatment
Psychological factors
Sociological factors
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Pain Assessment
> Individualised- what does it mean to the patient?
> Subjective
> Quality of Life- pain diaries
> Identify neuropathic elements
> Identify safety issues
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Pharmacy
Pain Management-Principles of Treatment
Pharmacy
- By the Mouth
- By the Clock
- By the Ladder
- Individualised treatment
- Patient involvement & goal setting > they manage pain
not the reverse
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WHO 3 step ladder
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Pharmacy
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
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NSAIDs
Pharmacy
 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
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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
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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 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.
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Neuropathic pain
Adjuvant Analgesics Antidepressants
Tricyclic antidepressants
Amitriptyline/ Nortriptyline/ Clomipramine
Unlicensed use
Beneficial in neuropathic ‘burning’ pain
SNRI
Duloxetine/ Venlafaxine
Unlicensed use
Improves mood and increases Serotonin& Noradrenaline at synapses
SSRI- no real evidence
Fluoxetine/ paroxetine
Unlicensed use
Improves mood and increases Serotonin at synapses
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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
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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
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Topical 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
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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
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Osteoarthritis
- 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
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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 Xrays
- Flares & relapses
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Rheumatoid Arthritis
Treatment aims:
Pain & inflammation relief
Preserve joint damage
Preserve / improve joint function
Treatment
DMARDs
NSAIDs
Simple analgesics
Systemic steroids
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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
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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
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Self-help
Pharmacy
Encourage exercise e.g. Walking and tai chi
Self-help e.g. Pain Association
Acupuncture, acupressure are helpful-TENS machines
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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%)
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Continued prescribed
Pharmacy
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
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Continued
Pharmacy
9 (22%) prescribed NSAID reported having an ulcer or
gastric symptoms, only 5 out of the 9 were coprescribed 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.
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Continued-Care issues
Pharmacy
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
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Why get involved?
Pharmacy
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
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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
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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
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Pharmacy
Pharmacy
Thank you
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