Pain can be, well, a real pain to manage if you don't know where to start but PB Young Pharmacist of the Year Pupinder Singh Ghatora surveys the most common complaints and the best products on the market to guide community pharmacists...

Pain is one of the commonest complaints we come across in community pharmacy.  The conditions I have come across have varied dramatically, from simple tension headaches to broken limbs (obviously referred to A&E immediately). In this article I want to try and cover the most common pain-related ailments we as community pharmacists are likely to come across, and then how best to treat them. 
The pain relief market in Europe is worth in excess of $60 billion. In the UK it is thought to be worth at present in excess of £700 million.  This is a market that is not difficult to make the most of. Common ailments we come across in pharmacy are:
Headaches
Sports Injuries
Muscle related pain
Back pain

There are many different types of headaches; one of the most common is the tension headache.  Telltale signs are a headache that feels like a band across the forehead. Common causes are the stresses and trials and tribulations of everyday life. Treatments can vary from systemic analgesics containing paracetamol, ibuprofen, aspirin and in combination with the three mentioned, codeine. There are now also many topical preparations and these rely on the cooling sensation to relieve pain.
Whenever I am recommending any treatment for any type of pain I always try to gauge the severity of discomfort by using a number scale: 0 – Mild pain. 5- Moderate pain. 10 – Unbearable pain.
I think patients find it much easier to quantify their pain rather than being asked to describe it. The severity of pain usually determines the type of treatment I recommend. If the pain is not too severe I recommend a paracetamol only based product. 
These range from generic products through to the Panadol range. If the headache is more severe, then the treatment takes a step up, in most cases to an Ibuprofen-based product. Ibuprofen is also thought to have a mild muscle relaxant effect and this can be helpful in tension headaches as the pain is often caused by muscular tension. If the headache is causing sever discomfort the treatment is stepped up again to a codeine containing product. 
For example, Co-codamol, Nurofen, plus or one of my favourite recommendations Propain or Propain Plus, these both contain paracetamol, codeine and also diphenydramine – a drowsy antihistamine. The combination of these products provide very effective analgesia and also relax the muscles and therefore also help to reduce the severity of pain associated with a tension headache.
Migraines are also another common ailment we come across in my store. Before sumatriptan was switched from POM to P, I used to recommend Nurofen Migraine Relief for moderate migraine symptoms. If however, the pain was more severe, the treatment would consist of a codeine containing product such as Nurofen Plus or Paramol. Now that Imigran Relief is available, this is my primary recommendation for migraine. 
It is important to ensure the diagnosis is correct and the headache is definitely a migraine before recommending any products. Nausea is a common symptom that is felt before full blown migraine pain occurs. In this instance the Migraleve range of products are useful as the pink tablet contains paracetamol, codeine and buclizine.  The buclizine acts an anti-emetic in combination with paracetamol and codeine and this is quite an effective treatment. It is important when recommending Imigran Recovey that the Glaxo-supplied questionnaire is completed prior to sale to ensure the treatment is suitable for the patient.
There are now also topical preparations available to help in the treatment of headaches. These consist of the 4head range, Kool ‘n’ Soothe and Migrain Ice. They all work using the same principle; cooling the area which can help block pain signals caused by tension headaches and relax the muscles in the head. After applying any of the listed treatments the patient feels a soothing, cooling and tingling sensation. A clinical trial with tension headache found that sufferers confirmed that after applying 4head they could feel the effects of its powerful natural painkiller, pure levomenthol (peppermint), getting to work in just two minutes. I normally recommend these products as link sales with systemic analgesics and so far have had very good feedback from my patients.

Sports injuries are becoming more and more common now since more and more people are working out and perhaps not preparing themselves before carrying out strenuous exercise. Here is where the R.I.C.E acronym comes into effect;
R – Resting the injury
I – Ice reduces swelling
C- Compression again reduces swelling
E – Elevation to reduce inflammation

These are good steps to follow if someone has a muscular injury. Ice and compression are very effective soon after the injury has occurred as it reduces the duration of the inflammatory cycle. The normal healing time for a muscular sprain or strain is normally six weeks for 100% recovery. However, 70-80% healing can take place up to four weeks after.
There is a huge range of treatments available for the treatment of these types of injuries. They include systemic NSAIDs which will reduce pain and also inflammation and hence decrease healing time. These are used when the injury is quite severe, otherwise a topical NSAID will usually suffice, one of the latest being Voltarol gel, a topical diclofenac preparation.
I normally recommend a warming product to use after two weeks of the injury as this often helps to loosen up the muscles and reduce the chance of stiffness occurring as a result of the injury. Perskindol has come up with a novel way of treating minor muscle injuries – the gel actually cools the site of injury initially and therefore reduces the inflammation and then after 10 to 15  minutes it has a warming effect. We have had many positive responses to this product in my pharmacy.
There are also various support and bandages that will give support and compression to the injury site and these vary from the basic Tubigrip products to the more specialised Neoprene-based products which give extra support and warmth to an injury – these are especially useful for athletes who require that extra support.
One of the most common ailments we are asked about is period cramps. These are treated by anti-inflammatories such as Feminax Ultra (Naproxen) or Ibuprofen-based products. In severe cases I may also recommend products that also contain codeine. The NSAIDs, as well as treating pain, also have a muscle relaxant effect and hence are of great benefit in the cramping associated with the menstrual cycle. 
A hot water bottle or heat patch such as the Cura-heat period patches are often recommended as a link sale by my staff and are proving to be quite popular. TENS machines have also proved their effectiveness in our business as we now have regular patients buying new electrodes for their machines which were originally sold to them to help period cramps. If pharmacy treatment still does not help, I  recommend the patient see their GP who will often put them on a contraceptive pill. This often helps to reduce period pain. 
There are also symptoms that should trigger referral straight away, these being: consistently irregular periods, bleeding in between periods, bleeding that become heavier than the previous period and also pain during intercourse. These may indicate the presence of fibroids in the uterus which will require further investigation and perhaps referral to a gynaecologist.
Back pain is an ailment that I am finding is becoming more and more common in my pharmacy. The most common cause is poor posture due to being hunched over a computer screen for a long period of time (yes, all of us do it!). Treatments consist of NSAIDs, both topical and systemic. 
One of the newest on the market is Voltarol Pain Eze – my patients who have tried this have found it to be extremely effective. We have now also found many alternative topical therapies, a favourite link sale of which is the Weleda Arnica Massage Balm. The consistency of this product means a little goes a very long way. Arnica is also thought to aid the healing process. Many of my patients find that massaging the area as well as using systemic painkillers do help in relieving most pain symptoms.
In summary it can be seen that the analgesic market is an easily accessible opportunity for community pharmacists to increase their OTC sales and further develop their businesses and, with all the recent POM to P switches in this sector, the opportunities are increasing all the time.

Cut-out quote     “I think patients find it much easier to quantify their pain rather than being asked to describe it. The severity of pain usually determines the type of treatment I recommend. If the pain is not too severe I recommend a paracetamol only based product.”