LESS PAIN

Less Pain
The results of a community pharmacy
pilot pain service evaluation
Summary
It is estimated that at any one time a million people in the UK are suffering from pain that could be significantly
better treated. Managing this challenge more efficiently promises significant health gains. The findings presented
here, along with those of other studies recently undertaken in England and Scotland, strengthen the case for
developing primary care in a manner that will enable community pharmacists to contribute in timely and (cost)
effective ways to the identification and treatment of people in pain.
This pilot evaluation involved ten community pharmacies located in north London, in each of which pharmacists
who had attended a half day training session performed enhanced pain-related Medicines Use Reviews (MURs)
with up to 20 service users. The customers involved were taking NHS prescribed analgesics and/or over-thecounter purchased medicines for the relief of pain. The aims of this research included identifying those who
were not using medicines to optimum effect, who were suffering – or were at unduly high risk of suffering – from
avoidable side effects, and/or who were not obtaining satisfactory pain relief because of factors such as having
undiagnosed neuropathic pain, or pain with a mixed aetiology.
A total of 176 enhanced pain MURs were performed over a total period of six weeks. The participating community
pharmacists reported making 182 interventions (some patients received more than one), with 12 per cent (20) of the
individuals consulting being referred on to their GPs to address side effects such as gastrointestinal disturbances
due to NSAID or opioid use. In addition, 11 per cent were referred to their GPs because the supply of enhanced
pain relief or another medication change was judged desirable by the pharmacist. Over and above this, five per
cent (9 individuals) were referred because it was likely they were suffering from undiagnosed neuropathic (or
mixed) pain.
If scaled up to a national service in England, these findings suggest that community pharmacists could identify
50,000 or more cases of neuropathic pain in a year and in the order of 10,000 cases of other serious illness
involving pain, such as – for example – angina. They could also provide in excess of a million guidance sessions
for pharmacy users with pain related problems. This ought in certain instances – such as the management of
recurrent headaches – to reduce counter-productive self purchased and/or prescribed medicines use.
The NHS in England has many competing demands on its resources. But despite fears that the better identification
of pain related needs in the population will increase some costs – which may on occasions discourage the
identification of inadequately treated adaptive or maladaptive pain – there is mounting evidence that improving
the early detection and effective management of pain related problems in the primary and community care setting
would be cost effective. Current service developments in Scotland in localities such as Fife might offer models for
better future care in England.
Introduction
There is – notwithstanding the limits of the available
research – evidence of a significant volume of avoidable
distress, including losses of both functional ability and
subjective wellbeing, associated with the sub-optimal
treatment of adaptive and maladaptive chronic pain in
the UK and elsewhere. A recently published National
Pain Audit (Healthcare Quality Improvement Partnership,
2012) and the Health Survey for England 2011 (Health
and Social Care Information Centre, 2012) both
indicated that about ten per cent of adults in this country
(that is, in the order of 4 million individuals) are at any
one time suffering from high grade chronic pain. Those
living with severe chronic pain have an average quality
of life score (measured using the EQ5D-3L) of only 0.4,
when 1 represents perfect health. This compares with
the impact of neurological conditions such as advanced
Parkinson’s disease.
Although further investigations should be conducted,
it has been estimated that approximately one million
people in the UK could at any one time benefit
significantly from better pain treatment (Gill et al., 2012).
Previously published calculations indicate that additional
investments in NHS pain care services of up to one per
cent of total health service costs might well be justifiable in
welfare economics based terms, even applying relatively
conservative affordability criteria. However, regardless of
whether or not this interpretation of the available data
is accepted, the likelihood in practice of additional NHS
resources becoming available on such a scale is low in
the current financial climate.
It is also of note that even if spending on tertiary pain case
referral centres were to be doubled they would only have
the capacity to treat about one in every 50 people who
are living with, or are at high risk of developing, debilitating
chronic pain. The National Audit referred to above also
raised implicit questions as to the cost effectiveness of
increased investment in such centres, which typically
only receive patients with well established problems.
Improving existing primary care and complementary
public health services may therefore be seen as a
desirable option in relation to pain management at both
the individual and population levels. This will be especially
so if progress can be achieved in ways that facilitate the
early delivery of effective pain related interventions that
demonstrably reduce the later occurrence of intractable
problems in people’s lives1. Apart from relieving subjective
distress, such developments might also help to limit the
tangible health service and wider costs associated with
conditions like, for instance, lower-back pain (Karjalainen
et al., 2004).
Against this background many pharmacists already have
(albeit often under-used) skills relevant to the needs of
people living with long term conditions. For example,
medication adherence and blood pressure control in
patients being treated with anti-hypertensive drugs has
been improved in patients attending sessions with a
hospital pharmacist (Morgado et al., 2011). Likewise the
involvement of community pharmacists has been shown
to improve the management of cardiovascular disease
risks (Horgan et al., 2010) and conditions such as type 2
diabetes (Mehuys et al., 2011). There is no reason, given
appropriate expectations and competencies, why clinical
care given by pharmacists should not be as effective as
that provided by any other health professional.
In the order of 80 per cent of the UK public already
say that pain is a symptom or condition about which
they would consult their pharmacist (Carr/Hammell
Communications, 2011). Furthermore, two recent
pilot studies have provided evidence that community
pharmacist prescribers can effectively manage patients’
pain. One resulted in a significant reduction in Verbal
Rating Scale scores for pain intensity, plus savings of
£11,000 per year due to prescribing efficiencies (Fife
Integrated Pain Management Service, 2012). The other
led to improvements in Visual Analogue Scale scores for
pain in 62 per cent of patients (Rose, 2012).
Another Scottish study by Bruhn et al (2011) showed
that community pharmacist prescribers working within
GP practices were able to improve the wellbeing of about
half the patients with chronic pain whom they treated.
This compared well with the proportion of service users
gaining benefit from medication use reviews delivered
in the same setting. The service offered was popular
amongst patients, and to a somewhat lesser degree
amongst their GPs.
A primary aim of the project reported here was to evaluate
the LESS PAIN instrument – see appendix 1, page 10.
This contains a series of questions that were produced
on the basis of the research findings detailed in the report
Relieving Persistent Pain, Improving Outcomes (Gill et
al., 2012). The LESS PAIN approach was designed
to facilitate well informed semi-structured discussions
between community pharmacists and service users with
pain related problems. LESS PAIN based consultations
seek to identify people with persistent pain who are not
using analgesic and adjuvant medicines effectively, are
suffering from avoidable side effects, and/or are not
getting effective pain relief because of problems such
as undiagnosed or inadequately treated neuropathic or
mixed pain. This present evaluation seeks to contribute to
further improving pain related pharmaceutical care. It was
also intended to help support the ongoing development of
community pharmacy/pharmacist research capabilities.
1 There is, as yet at least, limited published evidence that early
stage treatment programmes can halt at a physiological level
the development of chronic maladaptive pain. There is however
more evidence indicating that the early, effective, treatment
of neuropathic and/or other forms of pain can prevent the
development of maladaptive social and behavioural responses,
associated with failures to cope with pain as well as possible
(Perez et al., 2013).
2
Less Pain: The results of a community pharmacy pilot pain service evaluation
Methods
Ten north London pharmacies were purposively recruited.
A pharmacist in one of these led a prior evaluation of the
proposed intervention. This ran for two weeks before the
main evaluation period. (Data generated during this initial
phase were included in the overall analysis.) Findings from
this exercise influenced the content of the final materials
and guidance given to the lead pharmacists from the
other nine pharmacies during a half-day training course
held at the Royal Pharmaceutical Society. This sought to
provide them with the skills and information required to
perform ‘enhanced pain-related MURs’ for people using
both NHS supplied and personally purchased medicines
for the relief of pain.
After this initial training and standard setting process each
pharmacy was asked to perform enhanced pain related
MURs on up to 20 service users in a period of up to
six weeks. Volunteer participants were recruited into the
evaluation if they were receiving NHS funded analgesics,
reported pain related concerns to their pharmacists,
or were using self purchased analgesics. Community
pharmacy posters (similar in concept to pharmacy
posters developed in Scotland – Gilbert, 2012; 2013)
were displayed to increase pharmacy users’ awareness
of the opportunity to access this service.
(It was emphasised that this was an entirely free choice,
offered in part to permit the opportunity of taking part
in a follow up survey should this be undertaken.) When
service users did not wish their identities to be revealed
all project records were anonymised and assigned a
unique number by the pharmacist concerned, before
being passed on for analysis. All documentation has
been stored securely.
Patients using the service being evaluated were also
asked to complete a feedback form containing seven
statements with Likert-scale response options ranging
from ‘very strongly disagree’ (scored 1) to ‘very strongly
agree’ (7). The individual statements included: ‘I felt
comfortable talking to my pharmacist about my pain’,
‘I found the consultation with my pharmacist valuable’,
‘I feel better able to deal with my pain than I did before
I spoke to my pharmacist’, ‘The pharmacist reduced
my worries about my pain’, ‘The pharmacist helped me
understand how my medication would improve my pain’
and ‘The pharmacist helped me address possible sideeffects’. The feedback form also contained space for
free comment. At the end of the project semi-structured
qualitative interviews were in addition carried out with
leads pharmacists, either individually or in a group
setting.
Each patient completed a Brief Pain Inventory
questionnaire, in order to provide a preliminary measure
of their experienced difficulties. Using the LESS PAIN
question set as a guide, the pharmacist involved then
spent time talking to the individual concerned about their
current medication, the duration, extent and nature of
their pain, and any worries that they had about issues
such as treatment side effects. In instances where a
neuropathic pain component was suspected (because
of, for example, the use of pain descriptors such as
‘tingling’, ‘electric-shock like’ or ‘burning’, and/or
disappointing responses to medicines such as NSAIDs)
the painDETECT questionnaire (Freynhagen et al., 2006)
was also employed.
Results
The community pharmacist researchers recorded case
related information received during the enhanced MURs.
They also noted that the interventions made (including
the supply of information and advice or referral to the
customer’s GP for problems such as inadequately
treated pain, unwanted side effects or suspected
neuropathic/mixed component pain) and whether or
not they thought patients would benefit from the pain
management related MUR provided. Where a GP referral
was part of the outcome for individuals already in receipt
of relevant NHS care the standard (national) form for
reporting MURs to GPs was completed and passed on
to the prescriber, with a copy of the completed (local)
project enhanced MUR worksheet.
Figure 1: Ages of the people receiving enhanced
pain MURs (percentages of all participants)
The UCL Research Ethics Committee Chairman was
verbally informed of this research during planning. It was
subsequently concluded that the pursuit of formal ethics
approval was not necessary as this project was regarded
as a service evaluation. All participants were asked if they
wished their identities to be revealed to UCL researchers.
A total of 176 pain-related MURs were carried out by
the ten pharmacies over the research period (two weeks
for the pilot and six weeks for the main project). The
maximum number completed by any pharmacy was 20,
the minimum was 10, and the mean was 17.6. Forty
percent of the participants were male, 54 per cent were
female and the remaining six percent were unrecorded.
The ages of the participants were available in 146 cases.
They ranged from 17 to 94 (Figure 1), with a mean of 52
years. Ethnically, the majority of participants were White
British (48 per cent) or Bangladeshi (26 per cent). This
broadly reflects the relevant local population structures.
35
Number of individuals
30
25
20
15
10
5
0
0-1011-2021-3031-40 41-50 51-6061-70 71-80 81-90 91-100
Decade (years)
The painDETECT tool was used in 101 instances, with
the reported scores ranging from -1 and 0 (a neuropathic
pain component is unlikely) to 32 (a neuropathic pain
component is likely). The maximum possible painDETECT
Less pain: The results of a community pharmacy pilot pain service evaluation
3
Figure 3: Analgesic medicines (prescribed
and self-purchased) being used per study
participant
80
70
60
Number of individuals
score is 38, and the threshold level at which (subject
to other observed factors) neuropathic pain is normally
suspected is over 18. In this evaluation the average
score was 13. The overall distribution is shown in Figure
2a and the distribution of each of three main groupings
(a neuropathic pain component is unlikely, a neuropathic
pain component is possible, and the presence of
neuropathic pain is likely) in Figure 2b.
Figure 2a: Distribution of painDETECT scores,
n=101
50
40
30
20
8
10
7
0
012 3457
Number of analgesic drugs per patient
5
Note: analgesic medicines as defined here include NSAIDs, opioids
(including transdermal patches), paracetamol, anticonvulsants,
antidepressants or topical treatments (NSAID gels and capsaicin
cream). No-one in the sample was recorded as taking 6 medicines.
4
3
2
1
0
Pain Detect Score
Note: painDETECT scale ranges from 0 (neuropathic pain component
is unlikely) to up to 38 (a neuropathic pain component is very likely),
although it is possible to achieve a score of -1.
Figure 2b: Distribution of the three different
painDETECT outcome possibilities
60
40
30
Figure 4: Numbers of analgesic prescription or
OTC medicine items in use by drug type
20
10
0
120
Neuropathic pain is
likely (19-38)
100
4
80
Fentanyl
patches
60
Butrans
patches
40
Opioid
agonist
20
10
Opiate
Pregabalin
Gabapentin
l
ge
ID
SA
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D
N
SA
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As
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The data recorded also included the number of self
purchased (OTC) or prescribed analgesic medicines
used by each patient. The term analgesic drug was for
the purposes of this evaluation taken to include any of
the following: NSAIDs, opioids (all products combined,
including – for instance – fentanyl and buprenorphine
patches), paracetamol, anticonvulsants, antidepressants
or topical pain treatments (such as NSAID gels and
capsaicin cream). A total of 401 analgesic medicine
prescription and OTC items were found to be being used
by the people participating at the time of their reviews.
Some 74 per cent of the pharmacy service users involved
were taking more than one drug to control their pain.
The number of analgesic medicine prescription items or
OTC packs that had been supplied to each individual
ranged from zero to seven, with an average of just over
two (Figure 3).
am
Neuropathic pain may be
present (13-18)
Number of items
Neuropathic pain
component is unlikely (0-12)
ac
et
Number of individuals
50
As expected on the basis of published national statistics,
non-steroidal anti-inflammatory drugs (NSAIDs) were
the most frequently used type of analgesic medicine
(Figure 4). They were supplied (either via prescription
or purchased by the service user) on 112 separate
occasions, whilst paracetamol and paracetamol
combination medicines (such as paracetamol plus either
a weak opioid such as dihydrocodeine or an NSAID)
were dispensed in 83 and 68 instances respectively.
Forty-five patients were using either antidepressants
or anticonvulsants, suggesting that up to a quarter of
the people participating were suffering from previously
diagnosed neuropathic or mixed pain. Over a third of
all those involved in this evaluation were using an OTC
analgesic (most commonly paracetamol or an NSAID),
alone or alongside prescribed analgesic medications.
Pa
r
Number of individuals
6
Note: As some individuals were using more than one analgesic the
total count stated here was about twice the number of service users
who elected to be in the study.
* Nine people received aspirin, but only one appeared to be using this
medicine for its analgesic effect
Less Pain: The results of a community pharmacy pilot pain service evaluation
As indicated above and in Figure 5 below, a total of 186
interventions were made, with some patients requiring
more than one. Each intervention was assigned to one
of six categories, which were:
• the patient/service user was advised to take/referred
to their GP for a Proton Pump Inhibitor (PPI), to
minimise potential gastrointestinal damage from long
term NSAID use;
• the patient/service user was advised to take/referred
to their GP for a laxative/stool softener to minimise the
side effects of opioids;
• the service user was referred to their GP because of
other side effect related concerns;
• the individual was referred to their GP for consideration
of an alternative/additional medication prescription;
• the patient was referred to their GP for suspected
undiagnosed neuropathic (or mixed) pain; and/or
• additional information and/or advice was supplied to
the service user by the pharmacist.
The most frequent intervention made by pharmacists
was the delivery of advice and/or information,
typically relating to the correct use of medicines. This
encompassed, for example, pointing out the best time of
day to take amitriptyline to avoid feelings of drowsiness,
and advice about taking NSAIDs with food to minimise
gastrointestinal disturbance risks. Just over ten per cent
of patients (20 individuals) were referred to their GPs
for the consideration of an alternative medication or a
dosage review. In most cases this was because the
treatment being administered was not providing sufficient
pain relief. One patient was referred to his GP because
the pharmacist recognised that the intermittent chest
pain he was experiencing was angina, as opposed to the
‘chest strain’ reported by the individual concerned. In
this case the GP prescribed a nitroglycerin spray which
the patient was pleased subsequently to report eased
his pain satisfactorily.
Figure 5: The interventions made by the
participating pharmacists
Advised to use (or referred to GP
for) Proton Pump Inhibitor (7%)
Advised to use (or referred to GP for)
laxative/stool softener (4%)
Referred to GP for other
side effect (1%)
Referred to GP for
alternative medication
(11%)
Information and advice
given to patient by
pharmacist (72%)
Referred to GP for
undiagnosed
neuropathic pain (5%)
Relatively large numbers of medicine users were found to
be suffering, or at high risk of suffering, from side effects
that could potentially be avoided. Hence seven per cent
(13 individuals) were advised to consider taking a proton
pump inhibitor (PPI) to limit the unwanted effects of long
term NSAID use. A further four per cent (7 individuals)
were advised to use a laxative and/or stool softener to
address the issue of constipation caused by opioid use.
Finally, the pharmacists taking part in this pilot service
evaluation were able to identify nine patients who they
judged probably had an undiagnosed neuropathic
component to their pain (identified via use of the
painDETECT tool and patients’ own pain descriptors
and history) but were not taking an analgesic medicine
effective for this indication. These individuals were
referred to their GPs for further investigation. There were
an additional four people whose painDETECT scores
and pain descriptors may have merited a GP referral,
but were not so referred.
The participant pharmacists were asked to offer an
opinion on whether or not they thought the MUR
process would be beneficial for the service users. In 134
cases they judged that this would be so. This was most
commonly because it was hoped that the pharmacy
users involved would have an improved understanding of
their pain and/or how to take their medication effectively.
In addition, other patients were thought likely to benefit
from having unwanted side effects more effectively
addressed by their GPs, or from either stopping taking a
drug or switching to an alternative medication.
In the remaining cases the pharmacist either did not
answer the question (for nine patients) or (in 33 instances)
she or he did not think the intervention would add extra
value. This was most frequently because the patient
was already under the care of a specialist pain clinic
or was undergoing further investigation. (For example,
one individual was due to have an MRI scan in the near
future.) In other instances individuals appeared to have
acute conditions that were likely to resolve in a few days
(for example, pain due to a dental problem or what was
believed to be tonsillitis), had pain that was already well
managed and was not unduly impacting on their lives,
or were already well informed about the cause of their
pain and the pharmaceutical and other management
methods that they were using to treat it.
Almost 150 out of the 176 people who received an
enhanced pain MUR completed the feedback form. Of
these 17 also provided additional personal comments.
The average scores were either five (agree) or six
(strongly agree) for each test statement. Respondents
said that they generally felt comfortable talking to the
participant pharmacists about their pain, found the
service valuable, felt better able to deal with their pain
after their consultation, and had reduced worries about
their pain or had gained a better understanding of how
their medication works and the side effects involved.
The 17 pilot service users who left specific comments all
viewed it in a positive light.
Less pain: The results of a community pharmacy pilot pain service evaluation
5
The significance of such observations should not be
overstated. But they included:
‘I am extremely pleased with this service, I feel as
though my pain has been reduced already’
‘I consulted my pharmacist because he is much
more accessible than my GP practice. He has
given me time and very helpful information’
‘[The pharmacist was a] lovely person to talk to, it
helped for someone to listen’
‘It is a really good idea. I can come and speak to
someone without making an appointment’
‘I am pleased to know that I can speak at length
about my pain, normally the doctor does not have
much time [to spend on this issue]’
‘The pharmacist was amazing; he has considerably
reduced any worries. Thank you’
In terms of cost, running the service across the entire
eight weeks of the study in ten pharmacies involved an
outlay of approximately £12,000, including materials
for training, locum reimbursement for each pharmacist
attending the training session and a payment of £40
for each enhanced pain related MUR performed during
the project. This represents a total cost of about £70
per patient included. However, because much of the
expense incurred during this pilot related to activities
such as training and research feedback, considerable
economies of scale could be expected if such a service
were to be routinised. Current standard MURs in England
are delivered for a fee of just under £30. Pharmacists
taking part in this evaluation were also entitled to claim
this sum for the NHS MURs they conducted, which
would ordinarily be the total fee paid to them.
If a service aimed at the universal application of the
LESS PAIN instrument was rolled out nationally across
the circa 11,000 NHS community pharmacies, the
data presented here suggests that in a year community
pharmacies would identify in the order of 50,000
people with undiagnosed neuropathic pain, and around
10,000 other cases of serious illness involving pain as a
symptom. They could also, capacity permitting, deliver
around a million useful guidance sessions for pharmacy
users with other pain related problems.
Discussion
This pilot service evaluation offers further evidence that
community pharmacists can effectively play an extended
role in identifying and supporting people with both acute
and chronic pain, and in providing an improved standard
of treatment. The latter could enhance not only immediate
but longer term outcomes. Over the course of about
eight weeks (including the initial single pharmacy test
run) ten pharmacies successfully identified and referred
42 people to their GPs to address potentially resolvable
side effects or inadequate pain control. They in addition
found and referred nine people with what appeared to be
previously undiagnosed neuropathic pain, and provided
advice or information that could benefit approaching 100
other individuals.
6
In the specific context of neuropathic pain the data
gathered suggests that 45 people out of the total of
176 service users who elected to receive a pain related
enhanced MUR were already taking medication intended
for the control of this form of distress. Including those
instances where it is unclear from the available records
whether or not individuals were referred on to their GPs
by the pharmacists involved, 13 more people were found
to be likely to be suffering from neuropathic (or mixed)
pain.
This is consistent with other research indicating that
such pain tends to be under recognised and under
treated (Haanpää et al., 2009). These data imply that
a third of the total patient population involved were
experiencing a degree of neuropathic pain, compared
with a (conventionally) expected figure of about one
per cent in the general population. They can therefore
be seen as confirming that community pharmacies
provide an environment that is accessible to a significant
proportion of those affected by pain, and that there is a
considerable potential for improved outcomes.
The extent to which a national service based on the type
of pharmacy intervention described here would be cost
effective over a period of (say) a year cannot be reliably
calculated on the basis of the available results. Chronic
pain is often associated with other long term conditions
of later life like type 2 diabetes and osteoarthritis, and can
also be linked to deeply embedded attitudes and ways of
thinking. Such factors may underlie the recent National
Pain Audit conclusion that an improvement in quality of
life had occurred in only a half of patients six months
after starting attending specialist pain clinics, and that
as measured by the EQ5D instrument frequently used in
NICE evaluations the benefits observed were very limited
(Healthcare Quality Improvement Partnership 2012).
However, in the context of the findings reported here,
even if it were to be conservatively assumed that
only one QALY2 was generated in return for the entire
£12,000 direct project cost, this would still be within
the incremental NHS cost effectiveness affordability
parameters normally applied by NICE. This emphasises
the potential cost effectiveness of investment in primary
care level pain service improvement. But in order to
implement such a development on a national scale there
are a number of barriers that would need to be tackled.
For example, there is evidence that whilst many
pharmacists today view improving the public’s health
through interventions like those described here as part
of their role, enhanced service provision is commonly
2 For example, Moore et al., 2010 estimated in the context of
reducing moderate to severe pain associated with Fibromylagia
that gains equivalent to 0.1 QALY (Quality Adjusted Life Year) per
individual receiving better treatment are realisitically achievable. It
is reasonable to project that similar benefits could be associated
with, say, the identification of previously undiagnosed neuropathic
pain. If 10 pharmacies working for a period of 1.5 months
were to generate an additional health gain of 1 QALY, then a
national target of reducing the national pain burden by up to
10,000 QALYs per annum via medicines use optimisation and
allied interventions would be realistic. Using the criteria normally
employed by NICE such a gain in wellbeing could be valued at up
to £300 million in NHS affordability based terms.
Less Pain: The results of a community pharmacy pilot pain service evaluation
regarded as a task that is secondary to that of medicines
supply. Some pharmacists in addition appear to have
only limited confidence in their ability to supply ‘public
health’/clinical services, and regard a lack of time, space
and customer demand3 as barriers to increasing their
wider health and clinical care related responsibilities
(Eades et al., 2011).
streamline recording methods, and eliminate all but
vital reporting. Several of the pharmacists involved in
this evaluation suggested that increasing their clinical
workload will require the employment of two pharmacists
per pharmacy, along with a greater use of other skilled
staff, in order to allow clinical responsibilities to be given
the attention they deserve.
Such observations suggest an ongoing need for
educational reform, and additional professional
development support of the type provided during
this project. The latter need not be limited to pain
management related competencies. It could encompass
a range of clinical skills that would be useful for
community pharmacists involved in the care of people
with commonly presenting long term conditions,
including – for example – hypertension, raised lipid levels
and type 2 diabetes, as well as back and other arthritic
complaints and respiratory disorders such as asthma
and COPD. Extending community pharmacist clinical/
health services may also prove desirable in areas like
sexual health, fertility choice and weight and/or alcohol
use management.
In feedback sessions participant pharmacists also raised
under-dosing and other forms of medicines under-use
as a problem in the area of neuropathic pain treatment.
They made observations relating to all the main classes
of drugs used in this context, which is consistent
with the conclusions of other work carried out in both
England and Scotland (Torrance et al., 2013). They in
addition voiced concerns to the effect that they had not
previously been fully aware of the need for better quality
protective pharmaceutical care for people on long term
NSAID treatment, or the extent of confusion relating
to the safe use of over-the-counter medicines taken in
conjunction with prescribed drugs. Instances of patients
being under the impression that it is safe and desirable
to take multiple NSAID containing medications at the
same time were, for example, reported. Better pain
management will on occasions reduce use of both self
purchased and prescribed analgesics (NICE, 2012).
Feedback from community pharmacists involved in this
study suggests that the development of an integrated
set of assessment and care skills related to the types
of need commonly revealed during medication reviews
and allied pharmacist interactions with the public
could prove more valuable than fragmented ‘serial
developments’, that focus on promoting more narrowly
defined competencies. Seen from this perspective the
increased supply of pain related pharmacy services
could be regarded (as with smoking cessation service
provision and the support of people with illicit drug use
problems) as a useful stepping stone to a more general
role change.
However, having acknowledged this, many of the
participating pharmacists expressed surprise at the extent
of the specific need for better quality pain management
that their involvement in this study revealed. This implies
that in the shorter term at least policy makers might be
well advised to seek as a priority to introduce better
integrated local pain management services involving
community pharmacists and other primacy care and
allied providers (such as practice based and community
health service nurses) alongside GPs and secondary
care professionals. The example set in Scotland in areas
such as Fife might help provide a useful future model for
other parts of the UK.
A number of the community pharmacists who took part
in addition also said that they welcomed the discursive
(as opposed to ‘tick box’) nature of the dialogue that
the use of the LESS PAIN instrument encourages.
They further noted that if more clinically-focused and
on occasions time consuming ‘enhanced MUR’ type
service delivery is to become incorporated into normal
community pharmacy practice it will be important to
3 There is research indicating that patients exposed to appropriate
service models tend to believe that their pharmacists have more time
and may be better equipped to monitor and educate them about
(analgesic) medicines and their use than GPs (Bruhn et al., 2010).
Issues linked to non-adherence in relation to prescribed
analgesic medicines use were also highlighted in the
qualitative research undertaken as part of this evaluation.
In a number of instances it was said to pharmacists
contributing to this study that people were uncomfortable
discussing relevant concerns with their GPs. They had
instead elected to stop taking their medicines, even
when this led to episodes of limiting pain.
In association with phenomena such as this, some
pharmacists reported apparent cultural/ethnicity linked
differences in terms of the pain descriptors and severity
reported by patients. Such variations may to a degree be
reflected in Health Survey for England 2011 findings (see
Figure 6) showing that people living in poorer households
are more likely to experience having chronic pain (and
more severe chronic pain) than their more advantaged
peers (Bridges, 2012). However, such observations are
also linked to the strong association between ageing
and experiencing pain found in England.
Additional observations include:
• raising public expectations of community
pharmacy in the context of primary health care
delivery should be seen as a priority. Despite
recent trends, many people’s exposure to community
pharmacy-based health care has to date been limited.
This is one factor contributing to low expectations
of pharmacists as compared to GPs (Gidman et
al., 2012). However, the qualitative discussions
with pharmacists involved in this service evaluation
emphasised the reality that many service users are
happy to talk openly with them in private (rather than
‘over the counter’), given an understanding that the
pharmacist being addressed is willing to listen and
has time to discuss adequately the issues raised.
Less pain: The results of a community pharmacy pilot pain service evaluation
7
• using targeted personal support services to
complement wider public health programmes
might cost effectively improve health outcomes.
Enhancing patient and public knowledge about, for
instance, the importance of responding to different
types of pain appropriately could prove vital if
outcomes are to be improved efficiently. Arguably,
successful pain treatment often demands preventing
quality of life decreases as early as possible, rather
than attempting to institute corrective actions after a
decline has been experienced. The delays in getting
access to effective treatment that can be linked to
needing to be referred to a specialist pain clinic may,
as already noted, mean that by the time people are
treated in such settings their pain and the behaviours
that in some instances limit coping capacities have
become deep-seated.
Figure 6. Chronic pain grade by household
income and sex
Base: Aged 16 and over with chronic pain
100
90
80
Percent
70
60
50
40
30
20
10
0
Highest
2nd
3rd
4th
Lowest
Equivalised household income
Women
100
90
80
Percent
70
60
50
40
30
20
10
0
Highest
2nd
3rd
4th
Lowest
Equivalised household income
Source: Health Survey for England 2011, Copyright © 2012.
Re-used with the permission of the Health and Social Care
Information Centre.
8
Proportion who were moderately or extremely anxious or
depressed, by Chronic Pain Grade and sex
Men
Women
Base: Aged 16 and over with chronic pain
80
70
60
50
40
30
20
10
0
Grade 0
Grade I
Grade II
Grade III
Grade IV
Chronic Pain Grade
Source: Health Survey for England 2011, Copyright © 2012.
Re-used with the permission of the Health and Social Care
Information Centre.
Similar arguments apply to the need to ensure that
when individuals have become sensitive to public health
messages like ‘it is normally better to keep moving despite
having a backache’ or that ‘excessive use of OTC or
prescribed analgesics can lead to ‘rebound’ headaches
once their consumption is stopped’, sympathetic
pharmacy based or other forms of accessible primary
care provision are available to help individuals cope with
pain as effectively as possible.
The Health Survey for England 2011 also drew
attention to the close associations between chronic
pain and depression and anxiety (Figure 7). Data like
these underline the fact that a high prevalence of suboptimally treated chronic pain can be seen as a complex
public health issue that is systematically related to
wider problems associated with population ageing and
the prevention and treatment of non-communicable
conditions. This adds weight to the view that although
the most important long term public health goal may
be to foster the primary prevention of pain whenever
this is possible, enabling individuals to respond quickly
and effectively when entering a state of pain (secondary
prevention) is often in practice the most viable way
forward that is presently available (Taylor, 2013).
Grade I
Grade II
Grade III
Grade IV
Men
Figure 7. Pain, depression and anxiety
Percent
Participant pharmacists also reported that service
users appeared more likely to give them full and
accurate information about their health and medicine
taking behaviours during an ‘enhanced MUR’ than
when they are responding to the questions routinely
asked at pharmacy counters. Furthermore, they
observed that pain is often an emotive issue for
patients, as compared to problems like, say, having
raised blood pressure; and
Improving working relationships between community
pharmacists and GPs and establishing appropriate
remuneration schemes for pharmacies and/or
pharmacists providing pain or wider health care services
exemplify the type of measure that could help enhance
health service performance in the early 21st century.
From a commissioning perspective, further progress is
also required in areas such as ensuring that problems like
chronic pain are not neglected for inappropriate reasons,
like perceived cost saving opportunities. For instance,
it would be regrettable if community pharmacists were
in some localities discouraged from seeking to identify
undiagnosed cases of neuropathic pain because this
might temporarily increase pharmaceutical care costs.
One of the key lessons of the recent events in South
Staffordshire is that NHS managers should not allow
short term budgetary related imperatives to obscure
care quality priorities.
Less Pain: The results of a community pharmacy pilot pain service evaluation
Conclusion
This service evaluation has demonstrated that
community pharmacists are when provided with viable
opportunities both willing and able to play an extended
role in the care of people living with pain and pain related
problems. On their part, many pharmacy users are willing
to access and likely to value relatively low cost forms
of enhanced pain care delivered in familiar primary care
settings. Building on this and related research to develop
a nation-wide, evidence based, community pharmacy
pain management service could in future help protect the
quality of life of an increasing number of people affected
by chronic pain in ageing societies such as that of the
UK. It may also help to assure the efficient overall use
of health care resources, and lead on to wider primary
care improvements that involve community pharmacists
serving as health care professionals in the delivery of
better integrated clinical care for many more commonly
occurring long term conditions.
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posters in Scotland. Personal communication
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& McQuay HJ (2010) Fibromyalgia: Moderate and
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Less pain: The results of a community pharmacy pilot pain service evaluation
9
10
3
4
Severity? How much pain are you in? If we thought of a scale in which zero was no pain and
stabbing pain in a specific place or would you say it is a more generalised sort of pain?
Sensation? Can you describe exactly how it feels and where it is – is it, for example, a
10 was the worst pain imaginable, where would you place your pain?
Event? Is this pain linked to any particular event or illness, or has it come ‘out of the blue’?
2
Can you describe the pain you have, and say how long it has been troubling you?
Length?
1
The eight ‘LESS PAIN’ Questions
It is therefore important to manage all types of pain well. Pain lasting for a period of over two to three
months may be becoming a persistent pain condition. The eight broad ‘LESS PAIN’ questions below are
not to be asked or answered in a rigid or narrow way. Rather, they outline a range of issues that it can be
useful to talk about when considering pain related problems, given that each person is unique and needs
to communicate her or his special needs as effectively as possible.
Acute pain is by definition unpleasant. But experiencing it can also be vital, because it helps to prevent
tissue damage and aid repair. However, in some cases it may progress into a persistent pain condition
which brings with it no benefits. If inadequately treated, persistent (chronic) pain can for years needlessly
undermine the quality of life of those affected by it.
Community pharmacists are often the first health care professionals who people in acute pain come into
contact with, and one of the professional groups who individuals living with longer term pain are most
likely to see regularly. The questions below are intended to support discussions about pain between
pharmacy users and pharmacists. Thinking about them in advance of a pharmacy visit could, for
example, permit better communication than would otherwise be the case.
Eight ‘LESS PAIN’ questions to discuss with
your pharmacist when you are troubled by pain
Talking About Pain
anything you feel is important but may not be easy to talk about?
‘Not mentioned’ issues? Is there anything else concerning you about your pain –
alternatives such as meditation can be effective in changing pain thresholds. Are there any nonpharmaceutical treatments you wish to talk about or try?
Interventions? Psychological treatments such as Cognitive Behavioural Therapy or
unbearable? For example, is it interfering with your sleep or your social life?
Activity? Is your pain stopping your normal activities, or perhaps even making you feel life is
Prescription and over-the-counter medicines? How have you tried to relieve
it? Are you using medicines of any sort (prescribed, or that you have bought) and have you talked
about your pain with your GP or any other health professional?
Copyright © UCL School of Pharmacy and the UKCPA January 2012
The Talking About Pain communication guide for community pharmacy users was written by James
Davies, Dr Jennifer Gill, Dr Roger Knaggs and Professor David Taylor
Manage Your Pain.
Michael Nicholas, Allan Molloy, Lois Tonkin, Lee Beeston 3rd Ed (Harper Collins Australia 2011)
Overcoming Chronic Pain: A Self-Help Guide Using Cognitive Behavioural Techniques.
Frances Cole, Hazel Howden-Leach, Helen Macdonald, Catherine Carus
(Constable and Robinson 2005)
The Pain Toolkit http://www.paintoolkit.org
There are now many internet and other published resources for people living with pain. Examples include:
Resources
8
7
6
5
Appendix 1
Less Pain: The results of a community pharmacy pilot pain service evaluation
Less pain: The results of a community pharmacy pilot pain service evaluation
An opening question intended to initiate dialogue. The responses given should
be explored with prompting later. At first, seek information via supportive nondirective comment and if needed further open ended questioning (eg can you
say more about what you mean by that?)
1 Can you describe the pain you
have, and say how long it has
been troubling you?
Establish relevant history that the pharmacy customer/patient is aware of. As
appropriate, prompt on past record of migraine/headache, shingles, arthritic
disorders including episodes of back pain, diabetes and past experience
of surgery and diagnoses/events such as stroke or a previous diagnosis of
cancer. Without causing needless alarm (many people with pain fear cancer)
refer to GP if judged necessary.
Asking this provides further opportunity for establishing rapid rapport. Again
as a rule of thumb, pain that is scored 8 and above can be considered severe
and may warrant emergency intervention. Pain of moderate intensity (4-7)
should be regarded as requiring immediate intervention, while unexplained
persistent pain of any severity demands attention.
2 Is this pain linked to any
particular event or illness, or has
it come ‘out of the blue’?
3 How much pain are you in? If
we thought of a scale in which
zero was no pain and 10 was
the worst pain imaginable, where
would you place your pain?
As a rule of thumb, pain that has a duration of more than 3 months could be
a chronic/persistent problem, although in some circumstances pain of shorter
duration is indicative of a risk of developing chronicity.
Reason for question/possible interpretation of response
Question
This brief summary is intended for use in conjunction with the evidence and links to pain assessment and
allied instruments in the UCL School of Pharmacy/UKCPA report Relieving Persistent Pain, Improving
Health Outcomes (http://www.ukcpa.net/resource-centre). The table below is intended to facilitate
the interpretation of responses to the eight ‘LESS PAIN’ questions suggested in the Talking About Pain
patient communication leaflet.
Pharmacy based services could – in part through the extended use of pain assessment instruments – in
future help to identify more patients who are in the early stages of developing a persistent pain condition.
They might also facilitate access to other pain related services, including effective psychological care.
Persistent pain is a long-term, damaging condition which harms patients, their families and the wider
society. There are at any one time in this country in the order of one million people with pain related
problems that could have been prevented or be being better treated – too high a number for any one
health care provider group to handle alone. Millions more people have to cope with pain related problems
on a daily basis.
Interpreting pharmacy users’ responses to the
eight ‘LESS PAIN’ questions
Talking About Pain
Areas to evaluate range from the possibility that depressive illness is affecting
the respondent’s pain experience to that of normal physical activity being
unduly curtailed because of a false belief that a neuropathic or functional pain
is indicative of a continued risk of tissue damage. Indications that patients
are at risk of self harm because of pain may require emergency supervised
referral.
The logic of adjuvant therapy and/or psychological or other non-drug
interventions should be explained in an accessible manner to all chronic
pain patients. Some may be worried by being given medicines such as
anticonvulsants without an adequate explanation of the therapeutic rationale.
Others may benefit from signposting to locally available non-pharmacy
services. It may be helpful to communicate that modern pharmacy practice
is based on an informed awareness of both the benefits and the limitations of
medicines use, and that in areas such as persistent pain management drugs
alone rarely if ever provide a fully satisfactory solution.
Some people living with pain may be inhibited because of previous negative
experiences in consulting with other health professionals, or because they are
worried that their symptoms are an indication of cancer or another unwanted
diagnosis. Pharmacists should be able to alleviate such fears while eliciting
additional information and facilitating appropriate action whenever required.
Fear of or actual addiction to opioid or other analgesics may also fall into the
‘not easily discussed’ category.
6 Is your pain stopping your
normal activities, or perhaps
even making you feel life is
unbearable? For example, is it
interfering with your sleep or your
social life?
7 Psychological treatments
such as Cognitive Behavioural
Therapy or alternatives such as
meditation can be effective in
changing pain thresholds. Are
there any non-pharmaceutical
treatments you wish to talk about
or try?
8 Is there anything else concerning
you about your pain – anything
you feel is important but may not
be easy to talk about?
Copyright © UCL School of Pharmacy and the UKCPA January 2012
The Talking About Pain communication guide for Community Pharmacy users was written by James
Davies, Dr Jennifer Gill, Dr Roger Knaggs and Professor David Taylor
Establishing medication history and current use is good pharmaceutical
care practice. If neuropathic pain is present an NSAID is unlikely to be
effective. Guidance may be needed re effective and undesirable use of all
‘minor’ analgesics. Opioid users may also benefit from support with regard to
maximising relief by supporting adherence to planned medication regimens
and through minimising unwanted side effects via, for example, timely laxative
use.
A sharp, hot, stinging pain which is well localised and associated with
local and surrounding tenderness is most probably a somatic nociceptive
(inflammatory) pain. A dull cramping pain that is poorly localised may be a
visceral nociceptive pain. Use of words like burning, shooting or stabbing
along with an increase in sensitivity to painful and non-painful stimuli could
be indicative of a neuropathic pain problem. Prompt as required. Changes
in tissue colour, temperature and sweating suggest over-activity of the
sympathetic nervous system and may also point towards a neuropathic
component to the pain. If the pharmacist suspects neuropathic or functional
pain he or she might at any point offer a formal pain assessment.
5 How have you tried to relieve it?
Are you using medicines of any
sort (prescribed, or that you have
bought) and have you talked
about your pain with your GP or
any other health professional?
4 Can you describe exactly how
it feels and where it is – is it, for
example, a stabbing pain in a
specific place or would you say
it is a more generalised sort of
pain?
Appendix 2
11
The research reported here was supported by an unrestricted educational grant from Pfizer Ltd. This paper was
written by Dr Jennifer Gill and Professor David Taylor of the UCL School of Pharmacy and Professor Roger Knaggs
of the School of Pharmacy, University of Nottingham. They share accountability for its content and are grateful to
all those who contributed to this study. Particular thanks are due to Sanjay Ganvir of Greenlight Pharmacy and the
Camden LPC. Without his collaboration this work would not have been possible. Correspondence to Dr Jennifer
Gill ([email protected]).
Copies of this paper are available at www.ukcpa.net/resource-centre.
Copyright © UCL School of Pharmacy, April 2013 ISBN 13: 978-0-902936-26-3 Price £5.00
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