By Dr Lorraine de Gray
In the UK, every day 1.6 million people visit a pharmacy. Community pharmacists are easily accessible with over 11,600 community pharmacies in England. In 2017, Public Health England, in the document ‘A Way forward for Public Health’, stated: “Community pharmacy teams are in a unique position to reach out to different communities, age groups and gender across the life course and a vital partner in delivering public health interventions.”
There have been significant developments over recent years including changes in the law to allow pharmacists to prescribe. Pharmacists with a special Interest now specialise in the treatment of certain chronic medical conditions and promote healthy lifestyles such as obesity management and smoking cessation.
Across the UK, Clinical Commissioning Groups are funding ‘pain management’ and support services with community pharmacists. Plymouth is one area where a service has been designed to support patients in the management of chronic noncancer pain.
In their website, they list Key Service Outcomes as:
- Effective referral across the GP practice and community pharmacy interface.
- Identify patients who are engaged and ready to consider a reduction of their prescribed pain medicines.
- Support patients in the reduction of prescribed pain medication regimens, where appropriate.
Demonstrate the effectiveness of a community pharmacy-led intervention wherein advice and support is provided to patients on the management of their pain.
Patients have to meet any of the following three inclusion criteria:
- three or more pain-related medicines; or
- patients taking high dose of opioids regularly (>120mg morphine equivalent daily); or
- patients seeking pain medicines early, patients using large quantities of breakthrough medicine (e.g. Oramorph) or patients purchasing excessive additional painkillers over the counter.
For eligible patients, the pharmacist can conduct a Medication Use Review-style consultation, followed up by a second contact in the proceeding weeks. Similar services are available over other parts of the country including Norfolk, where I practise.
In the document ‘Opioids Aware’, written by the Faculty of Pain Medicine, and endorsed by Public Health England, pharmacists are described as being in a position to be the most accessible community health care professional for many patients.
Community pharmacists can, therefore, take a proactive approach in limiting the use of OTC analgesics containing Codeine or Dihydrocodeine in the management of acute pain. They can also monitor effectiveness and tolerance of opioids by carrying out Medicine Use Reviews. They can highlight unusual or suspicious drug-seeking behaviour or potential misuse of prescription drugs by requesting a review by the primary prescriber.
Community pharmacists can also play a significant role in the perioperative period and indeed have been shown to have a role in enhanced recovery. Transitional pain services provide a critical window to address opioid use, particularly in patients with a history of chronic pain and presurgical opioid use.
Around 50 per cent of patients are discharged home on opioids following major surgery and around three per cent have been shown to be still taking strong opioids 90 days postsurgery. Careful monitoring and support of these patients postoperatively by community pharmacists could contribute to better pain management, lessening the risk of chronic post-surgical pain and reducing inappropriate opioid usage.
Community pharmacists in collaboration with local GP surgeries can also provide better pain management by providing lifestyle advice promoting self-management of pain. Specialised independent pharmacist prescribers, who can issue prescriptions, can run regular pain clinics, actively monitor drug titration and in some instances assume a direct case management role.
This reduces GP workload and extends patient choice in ways that should also reduce pressures in hospital-based services, especially if good working links with the other community-based teams are developed. They can also signpost to appropriate psychological therapy or mental health services where required.
Community pharmacists are also in the position to recognise patients who are struggling at an early stage of pain and link with the corresponding primary or secondary care services.
The future will undoubtedly see more developments in community pharmacies across the country – development of IT systems, increasing number of prescribing specialist community pharmacists will all help to ensure optimal use of medications, improved communication across the multidisciplinary team thus ensuring patients continue to get excellent care from their local pharmacists, the unsung heroes.
Dr Lorraine de Gray is Vice Dean of the Faculty of Pain Medicine, Royal College of Anaesthetists.
This article also appears in the October issue of Pharmacy Business.