Aches and pains - Module 150
Make sure you understand the causes of aches and pains with our guide to these four common scenarios
• about different conditions that cause pain in older people
• what to recommend and when to refer to the pharmacist
• how to spot medical emergencies that require urgent treatment.
Download a pdf version of this module here
Download the Test Your Knowledge questions here
Scenario 1 Arthritis
A woman in her late 60s would like to buy some paracetamol tablets. "They are for my arthritis," she says. "The doctor has given me some pills that usually do the trick, but today I feel I need something extra and I'm sure he said that I could take paracetamol as well."
Arthritis is extremely common, affecting more than nine million people in the UK. This lady tells you she has osteoarthritis; this is the most common type, with around 8.5 million sufferers in the UK. It occurs when the cartilage between bones wastes away causing the bones to rub together, which leads to pain. It is most commonly seen in the hands, knees, spine and hips.
Most patients are over 50 years of age but it can occur at any age as a result of injury or another condition.
The other best known arthritic condition is rheumatoid arthritis. This is much less common and only affects around 350,000 people in the UK. It is generally worse than osteoarthritis and is caused when the body's immune system attacks and destroys joints. This causes pain and swelling, which in turn leads to reduced mobility and the breakdown of bone and cartilage. It tends to start between 40 and 50 years of age and is three times more common in women than men.
Unlike rheumatoid arthritis, where the cause is known, there is no known cause for osteoarthritis. Treatment is therefore limited to painkillers such as paracetamol and ibuprofen, and steroids. If medication ceases to be completely effective the next step is surgery, which could involve joint replacement, joint fusion or the addition or removal of bone.
You should first confirm the patient is not taking any other painkiller and that she does not have a condition that prevents her taking paracetamol, such as liver disease.
Once this is done it would be appropriate to suggest paracetamol, and recommend the lady visit her GP to discuss her pain relief, as it would appear that her prescribed medication is not enough to completely ease her symptoms.
Scenario 2 Fibromyalgia
A customer approaches you and asks if you have any information on fibromyalgia. "My doctor told me I have fibromyalgia and has given me some tablets but I would like to know more about it."
Fibromyalgia, also known as fibromyalgia syndrome, is a condition that causes pains in many different areas of the body and is often accompanied by extreme tiredness. Its cause is unknown and there is no known cure. It affects one in 20 people worldwide; the number of adult sufferers in England and Wales is thought to be as many as 1.76 million. It is more common in women and in people between 30 and 60 years of age, although it can develop at any age.
The main symptom is pain, which can vary in severity from day to day but may be made worse by stress, cold or activity. Some people feel the pain ‘all over', with the neck and back often being the most painful, while many areas of the body may also be quite tender. The other main symptom is tiredness or fatigue, which can be so severe that it becomes more distressing than the pain.
Difficulty sleeping, headaches, irritable bowel syndrome (IBS), muscle stiffness and depression are all associated with the syndrome.
Treatment is not straight forward. Most patients are prescribed a combination of medications, usually painkillers and antidepressants. Counselling may be recommended as well as certain lifestyle changes such as creating better sleeping habits, using relaxation techniques and taking regular exercise.
The extreme fatigue that is characteristic of this disease may mean that the patient feels unable to perform exercise. However, by performing regular aerobic and strengthening exercises symptoms can be managed and overall health improved.
You should see if your consulting area has any booklets on the condition, or ask the pharmacist to advise the customer. Alternatively, your dispensing computer may have a library of patient leaflets and you could print out any relevant advice.
Scenario 3 Sciatica
A 58-year-old man slowly approaches the counter and asks you for some advice. "I need something for my back. I was out gardening and think I may have pulled something. My back is agony and my left leg is tingling. Do I need to see the doctor?"
Back pain is extremely common and causes one in five people to visit their GP each year. It is classed as either specific or non-specific. Specific back pain is caused by an underlying health problem or by damage to the spine. Non-specific back pain is caused by sprains, strains, minor injuries or a pinched/irritated nerve and is the type that you will encounter more often in the pharmacy.
Given the customer's age and his description of the pain he may be suffering from sciatica, which is classed as any pain caused by irritation or compression of the sciatic nerve. Sciatica is a symptom and its treatment involves identifying and treating the underlying cause, the most common of which is a slipped disc.
As people age the discs that cushion and support each of the vertebra in the spine become tougher and more inclined to split. This causes the gel inside the disc to bulge outwards between the vertebrae, and if it presses against the sciatic nerve, sciatica results. Another cause of sciatica related to age is spinal stenosis, which involves the narrowing of nerve passages and causes the nerves to become squashed.
The sciatic nerve is the longest nerve in the body and symptoms of sciatica can be felt from the lower back, through the buttocks and down one or both legs to the feet. The pain can vary from fairly mild to extremely painful but it usually resolves itself within a few weeks.
As well as pain other symptoms of sciatica are numbness, tingling, muscle weakness and loss of tendon reflexes. Usually the use of over the counter painkillers, exercise and hot and cold packs is sufficient to relieve symptoms. Bed rest is not recommended; instead activity should be reduced at first and then gradually increased back to the individual's usual level.
It is best to check with the pharmacist before offering a treatment, but once you have you could recommend an ice pack for the first 48-72 hours, followed afterwards by a heat therapy.
You can also suggest, assuming they are suitable for the patient, paracetamol and ibuprofen to help with the pain.
Scenario 4 Drug side effects
A gentleman in his 60s would like something to ease the pains he has been experiencing in his legs. "I can't understand it" he says. "My legs feel like they've run a marathon but I've not done anything out of the ordinary that could cause them to ache so much."
As you go through the usual WWHAM questioning, he reveals that he has recently started to take some new medication, a statin, to reduce his cholesterol levels. After determining that the pains could not be due to exercise or injury it seems likely that they are a side effect of his medication.
Unexplained muscle weakness, pain, cramps or tenderness is a possible side effect of statins. It is not appropriate in this case to offer over the counter pain relief; instead the customer should be referred to the pharmacist, who will advise him to visit his GP as soon as possible.
Pain as a side effect of medication is not that unusual. It is thought that somewhere between 5-30 per cent of people prescribed statins will experience symptoms similar to those described above. Other drugs that can cause pain include opioid-based painkillers such as morphine, which commonly cause headache as a side effect. In fact, many drugs list headache as a possible side effect and consideration should always be given to the possibility that any medication a customer is taking could be causing other symptoms. This is particularly important in older customers who may be on a number of different therapies for different diseases.
Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are well known for their association with bleeding and ulceration in the stomach and/or intestine. This risk is greater in older patients.
Pain symptoms that require urgent referral
• Sudden chest pain radiating down left arm or into the neck – this could indicate a heart attack.
Sudden strong pain in the head – this could be due to a bleed in the brain.
• Severe pain after injury along with reduced or no mobility – this could be
a bone injury or dislocation.
• Unexplained muscle pain/weakness while taking a statin – this may be
a side effect of medication.
• Pain combined with redness and swelling – this could be an infection that requires antibiotics.
Key points
• If in doubt always check with your pharmacist.
• Remember medication can sometimes be the cause of symptoms.
• Always confirm the correct dosage instructions with the customer. People in severe pain may be tempted to over-medicate, which can result in
an increase in side effects.
• If over the counter medication is not adequate, the customer should be advised to visit their GP.
• Remember that customers may have reduced mobility and may be in pain. If possible serve them promptly and show them where they can sit down if necessary.
• Always exercise caution when recommending medication to older patients. They are often taking a number of different therapies and tend to be more susceptible to potential side effects.
Evaluation
• Do you know how to access information for patients regarding their medication or condition? Most pharmacies are now connected to the internet and many dispensing programmes come with a library of useful information.
• Take a look at the many products in your pharmacy aimed at relieving pain. Do you know what each one contains and when they should be recommended or avoided?
