An evaluation of the use and efficacy of analgesics in the management of chronic pain in the community
The main aims of this research were to evaluate the use and efficacy of analgesics in the management of chronic pain in the community and to investigate the role of the pharmacist in optimising health outcomes relating to chronic pain by assessing the effect of pharmacist intervention on pain control and activities of life. Cluster samples of patients with chronic non-malignant pain living at home were identified from 3 medical practices in 2 Scottish Health Board areas, using diagnosis of rheumatoid arthritis (RA) and repeat prescription of non-steroidal anti-inflammatory drugs (NSAIDs) and other analgesics as selection criteria. Structured interviews determined patients' use of prescription and non-prescription therapies for pain relief, attitude to medication and perceived side effects. Outcomes measured were pain relief, influence of pain on activities using a quality of life (QOL) scale and side effects experienced. Pain relief was assessed using the McGill Pain Questionnaire (MPQ) and horizontal visual analogue scales (VAS). Poor outcomes were defined as at least one of the following: poor pain control (VAS average pain greater than 75), total QOL score greater than 35, signs or symptoms of an adverse drug reaction, deliberate therapy change by patient due to lack of awareness of rationale of therapy or patient dissatisfaction. Patients with poor outcomes were given information or advice, referred to their GP and interviewed after 4 to 6 weeks to determine any changes in outcomes. A total of 109 patients were identified of whom 96 agreed to participate; 42 had RA, 22 had osteoarthritis (OA), 25 had both OA and RA and 7 had low back pain. Seventy-one patients were prescribed NSAIDs, 15 disease-modifiying agents (DMARDs) , 49 combination analgesics and 27 paracetamol. The majority of OA patients prescribed NSAIDs had no inflammation. Use of other therapies for pain e.g. anticonvulsants, hypnotics and herbal products was significantly higher in RA patients. Documentation of biochemical and haematological parameters in GP records was very limited. Twenty-eight patients had poor outcomes requiring GP referral, but also had significantly higher expectations of pain relief, higher pain and QOL scores compared to the 68 patients with satisfactory outcomes. Suggestions for changing therapy in 24 of the 28 patients were discussed with the GP, the other 4 requiring surgery. Although the pharmacist's recommendations were accepted and acted on in 22 of the 24 patients, 7 were unwilling and 3 were too ill to be re-interviewed during the study period. The pharmacist's recommendations were implemented in 12 of the 14 patients who had a follow-up interview. Pain scores and QOL scores improved in 9 and 8 patients respectively after pharmacist intervention. Twenty-four and 38 patients respectively with satisfactory outcomes required advice to improve concordance and to minimise the risk of side effects. Sixty-four patients reported side effects, 5 of whom required GP referral. Although there was a need for referral advice and information, the small number of patients followed up did not allow estimation of the outcome measures' sensitivity to pharmacist intervention, thus the second aim was not fully achieved. Potential pharmacist role(s) within a primary care chronic pain team were identified using questionnaires sent to a random selection of GPs, community pharmacists and physiotherapists. Most pharmacists wanted to provide more analgesic advice, a finding supported by most GPs and physiotherapists. This study has demonstrated both a need for pharmacist input into chronic pain management and evidence that such input would be welcomed.