Getting the balance right

Patient and professional education

Helen Liddell, who is involved in the Flippin’ Pain website, stresses that patient education is crucial. “We understand chronic pain better than ever before. If we explain the science of pain to patients and offer non-pharmacological alternatives, we will be able to manage pain better and minimise the use of drugs,” she comments. The Flippin’ Pain website provides resources and materials to support patients to better manage persistent pain.

“People are likely to consider pain as a symptom of an underlying condition rather than as a condition in its own right,” Emma Davies says. “By the time many people are given information about pain, they have lived with it and sought answers for a considerable time. At that point, patients can feel like they are being fobbed off by a professional who can’t think what to do, rather than it being an explanation in and of itself. 

“The best thing we can do is to find out what matters to the person living with pain. This can take time and requires trust on both sides. Finding out what people care about, what they miss, what they’d like to spend their time doing
is the best way to build motivation to change.”

For example, pharmacists could stress that acute pain arises from tissue damage. Chronic pain, in contrast, arises from changes to the nervous system. Partly because of this, Liddell stresses that coming off opiates does not usually happen overnight. 

“Reducing opioid use is a bit like smoking cessation: you have to wait until patients are ready. And, like smoking cessation, reducing opioid use takes time,” Liddell says. “Too many people are taken off opioids too quickly. Reducing or stopping opioids means retraining the nervous system. The pace needs to be controlled and, if necessary, part of a negotiated agreement. Coming off opioids can be a bit of a bumpy road.” 

Package of measures

Any plan to cut down opiate use should include the management of flares, which are almost inevitable. “It is important to have a package of measures to address the dynamic nature of chronic pain,” says Liddell. 

“It is wrong to suggest that medicines are bad or should not be used or offered to people with pain,” agrees Emma Davies, “but people prescribed analgesics should be regularly reviewed and when analgesics are not helping or causing harm, they should be reduced and, ideally, stopped. We should encourage patients to view analgesics as one part of the pain management jigsaw, rather than the whole picture.”

Both stress the importance of pharmacist education. Liddell is clinical director at MORPh Primary Care Network, which provides training about pain management for pharmacy teams. Davies is a co-founder of livewellwithpain.co.uk. 

“We felt there was a gap in terms of resources and training for professionals, especially in primary care. The website is free, although we encourage registration, which helps direct users to the most appropriate resources,” Davies explains. “In the five years since we started livewellwithpain.co.uk we have expanded the range of resources provided, including the ‘10 Footsteps’ programme.”

Developed as part of a research project with Durham University, the initiative improves outcomes and reduces the use of, and reliance on, analgesics. “There is a section on medicines and Footstep 9 considers the place of medicines in pain management,” Davies says. The 10 Footsteps is available in versions for patients, professionals and carers, which should, ideally, be used together. 

“The practitioner’s version goes through the footsteps with advice on how to encourage the patient to engage with the ideas and work through the resources, so that they get the best outcomes they can,” she says. 

Simple strategies

Sleep deprivation, stress and a lack of social contact can exacerbate chronic pain and are, potentially, modifiable. For example, poor quality and insufficient sleep increases the risk of chronic pain, hyperalgesia (increased sensitivity to painful stimuli) and pain symptoms (e.g. myalgia or headache). Chronic pain can also disturb sleep.

A cycle can become established, which often gradually deteriorates3, but as Anaesthesia notes: “Chronic pain can be associated with significant disruption in brain activity during sleep. Furthermore, this disruption is not improved, and may even be exacerbated, in patients taking opioid medication”.⁴

The public’s generally poor understanding of pain and its management means that patients may not easily accept non-medical interventions, says Davies. “Often non-medical interventions can appear hard work and are likely to take time to relieve pain and improve outcomes. In contrast, medicines remain relatively easy to get and are still considered likely to rapidly improve symptoms. 

“Pharmacists should ask the individual what they want to know about pain and how that may relate to their situation. We may want, for example, to break the myth that osteoarthritis and pain are the same thing. But if addressing misconceptions takes time away from helping the person to move on and change what they ‘do’ about their pain, then it may not be the best use of time.” 

“There is good evidence that getting and remaining active, moving more, losing weight, eating as well as you can, undertaking relaxation and mindfulness, and making time for hobbies can all improve quality of life, wellbeing and general health and, in turn, contribute to reductions in pain intensity and interference,” Davies adds. “However, we need to be careful about suggesting that anything works in isolation. 

“For many years self-management strategies were introduced when other ‘medical’ interventions had failed or been exhausted, so we need to be much better at introducing supported self-management at the first opportunity. Self-management strategies can benefit all pain types and should not be offered only when pain persists.” 

Intractable problems

Some risk factors for chronic pain are more intractable. For example, childhood physical, sexual and psychological abuse increase the risk that the person will develop chronic widespread pain as adults between two- and three-fold.⁵ Indeed, childhood abuse can increase the risk that adults will develop several conditions that cause persistent pain, including fibromyalgia, irritable bowel syndrome and chronic pelvic pain.⁵ 

“There is a very strong link between adverse childhood experiences and chronic pain,” Helen Liddell remarks. “Tackling these issues takes long-term counselling and support, which is not always available.” 

Pharmacists should refer patients they suspect of experiencing depression and anxiety to their GP. People living in chronic pain are more likely to experience clinically significant mood or anxiety symptoms. Depression is, for instance, three or four times more common among people with chronic pain than in the general population.⁶

Of course, living with pain can trigger anxiety and depression – but depression and distress can also increase the likelihood of transitioning between acute and chronic pain.⁵ Opiates may be less effective in people with negative affect (mood and anxiety symptoms). 

A study of people with back pain found that analgesia produced by oral opioids in people with high levels of negative affect was about half that in people with low negative affect.⁵ “Teasing out the relationships between depression and anxiety and chronic pain is often very difficult,” Liddell says.

“We now need to reframe our thinking and make sure ‘every contact counts’ with a patient living with persistent pain,” Liddell concludes. “Patients and healthcare professionals need to appreciate that reducing or stopping opioids means retraining the nervous system. 

“You can’t reduce or stop opioids overnight and there will probably be setbacks but, with support from their pharmacist, patients can move forward.”

References

1. Implementation Science 2022; 17:77
2. The Pharmacogenomics Journal 2022; 22:117-123
3. Neuropsychopharmacology 2020; 45:205-216
4. Anaesthesia 2016; 71:1296-1307