In this module you will learn:
- What pain is and the different ways it is described
- The difference between acute and chronic pain
- The underlying mechanism of how pain occurs in the body
- The benefits of managing pain with a topical product
Download this module - this includes the 5-minute test - here.
The content was authored by a pharmacist on behalf of C+D and has been reviewed by GSK in line with the PAGB code of practice.
Pharmacy is ideally placed to help customers suffering from musculoskeletal pain. Although patients can select from a number of treatments, with so many over-the-counter pain medicines available, customers are often confused regarding basic information about painkillers, such as active ingredients and strength.
This is why it is essential for pharmacy staff to be experts in the pain products available, and know how these products can benefit patients.
A global survey by GSK last year demonstrated that pain can have a severe impact on peoples’ daily lives – from negatively affecting their working life (78%) and their social life (72%), while 50% said pain “impacts their ability to enjoy life”.1 Managing pain is therefore essential in order to help people stay active and enjoy life to the full.
What is pain?
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.2
It often acts as an early warning sign to prevent potential or further damage to the body. Pain could be described as:
Subjective3,4 This is how patients experience pain, and it depends on several factors:
- A patient’s emotional and psychological state – if a patient is feeling low, their pain perception tends to increase
- Their memories of pain – for example, a bad memory of a dental pain may make new dental pain feel worse
- Their attitude – when people feel that it is necessary to finish a task, they may be able to work through the pain until it’s done
- Social and cultural beliefs – in some societies, complaining about pain is a sign of weakness, meaning some patients may suffer in silence
- Their preferences – if a patient believes it is best to use non-drug treatments to manage their pain, they will tend to respond better to these treatments.
Objective4,5 This is the physical process of experiencing pain. Pain results from a series of exchanges between three major parts of your nervous system: the nerves, spinal cord and brain.
For example, if a patient has a finger injury, the affected nerves send signals via the spinal cord to the brain, where these get interpreted as pain. In response, the brain causes a reaction to help avoid or prevent further damage.
Why pain occurs
Prostaglandins are a key mediator in the pain response. This hormone-like chemical is present throughout the body and helps maintain normal organ function. But some prostaglandins are responsible for the sensation of pain. 6
Pain relievers – such as paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) – work by suppressing prostaglandin synthesis. Paracetamol blocks prostaglandins in the central nervous system only, whereas oral NSAIDs work in the brain and also suppress activity in the peripheral nervous system.
However, NSAIDs can result in side effects in the gastrointestinal system, and organs such as the liver, the kidney and the heart can also be affected in rare cases. 7,8
Pain can be classified as either acute or chronic 2, 5, 10
Acute pain
This can be mild or severe and linked to an injury or disease, such as a backache, shoulder pain or muscle pain. It may last a few days or weeks, and goes away when the underlying cause is treated or healed.
Chronic pain
Pain is considered chronic when it is present on most days, and lasts for longer than three months. An example is arthritis.
Musculoskeletal pain – a common acute and chronic pain complaint – becomes more common with increasing age. Musculoskeletal pain covers a variety of disorders associated with:
- the joints and soft tissues implicated in moving those joints – usually the muscles, ligaments and tendons
- other muscle aches and pains – these are also common and may affect the neck, arms, shoulders, lower back, trunk or the hip. They can be caused by over-exercise, physically demanding work or trauma to the area. 11, 12, 13
Counselling patients
As pain is subjective, using open-ended questions when talking to patients is essential. This will enable the individual to express themselves in their own way and provide more meaningful responses.
Repeating phrases back to customers will help them to feel they have been listened to, while ensuring you understand clearly what the issue is. When speaking to a patient, establish how long they have had the pain and whether it has occurred before.
Using the WWHAM questions can help you determine what steps you can recommend.
- Who is the medication for?
- What are the symptoms?
- How long have you had the pain?
- What Action have you taken so far?
- Are you taking any other Medication?
These questions can help establish the most suitable treatment for the customer.
Treatment
Non-prescription pain relievers should only be used for the short-term management of pain. Although taking oral pain medication is the mainstay of treatment, topical therapy may be a suitable alternative for some patients.
Topical pain relievers have a lower risk of systemic side effects and interactions compared with some oral medications, such as NSAIDs.
Topical NSAIDs, such as diclofenac or ibuprofen, are used for mild to moderate acute musculoskeletal pain. They are available as gels and creams, and are absorbed through the skin and into injured tissue locally.
This means that a high concentration of the drug will reach the injured tissue, rather than being distributed by the blood to other organs, where they can cause adverse effects.
Voltarol has a range of topical products that can be used to relieve pain and inflammation, helping people stay active and enjoy movement, while preventing pain from interfering with their daily activities. The active ingredient in the full Voltarol product range, diclofenac, is absorbed through the skin where it works at the source of the pain.
Voltarol 12 Hour Emulgel P 2.32% Gel Diclofenac diethylammonium
- For all-day relief of joint pain without a tablet
- Relieves pain and reduces inflammation in painful conditions affecting the joints and muscles
- Not recommended for use in children under 14
- Convenient morning and evening application – recommended use for up to 14 days
- Available in 30, 50 and 100 g packs. The 100 g pack has an easy-to-open cap that enables people with stiff wrist and finger joints to twist and open the nozzle more easily than a normal cap.
Voltarol Pain-eze Emulgel Diclofenac diethylammonium
- Up to four times faster relief from muscle pain than a non-medicated gel 14, 15
- Apply after exercise for relief from muscle and joint injury
- Not recommended for use in children under 14
- Apply three to four times a day for up to seven days
- Available in 30, 50 and 100g packs.
Tips for your CPD entry on pain and its management
Reflect
What do you know about the effect that pain has on a patient? Do you understand the two major aspects of pain? Do you understand the role of prostaglandin in the mechanism of pain?
Plan
This module contains information about the pain sensation and the different aspects of pain. It also looks at advice pharmacists should consider when they counsel patients, and when they should refer patients who present with musculoskeletal pain.
Act
Read the Guide to topical pain relief module and complete the following suggested activities, then take the 5-minute test (below).
Read the guide to managing pain on the Pain Concern website, which contains advice to help patients understand and manage their pain.
To help your customers understand what body movements and exercises they can carry out to help prevent pain, refer them to the Voltarol website.
Read more about the contraindications and side effects associated with diclofenac in BNF chapter 10 section 4
Consider whether the pain management range within your pharmacy would benefit from some patient information leaflets or point-of-sale materials prompting customers to ask for help
Revise your knowledge of strains and sprains from the NHS Choices website.
Visit the consumer website to find out more about how the range of Voltarol products should be used to ensure you can give effective advice to customers.
Evaluate
Would you feel confident providing information on topical treatments for pain management? Do you understand the particular symptoms that warrant referral when a patient presents with musculoskeletal pain? Do you have any further learning needs?
References
- GSK Data on File. Global Pain Index, n=7,000+. February 2015.
- Merskey H, Bogduk N. Classification of chronic pain – second edition. IASP Press, Seattle (1994 reprinted 2002).
- Linton SJ, Shaw WS. Impact of psychological factors in the experience of pain. Phys Ther. 2011; 91(5): 700-711.
- Navratilova E, Porreca F. Reward and motivation in pain and pain relief. Nature Neuroscience 2014; 17(10): 1304-1312.
- Carr DB, Goudas LC. Acute pain. Lancet. 1999; 353(9169): 2051-2058.
- Miller SB. Prostaglandins in health and disease: an overview. Semin Arthritis Rheum. 2006; 36(1): 37-49.
- Cazacu I, Mogosan C, Loghin F. Safety issues of current analgesics: An update. Clujul Medical 2015; 88(2): 128-136.
- Golan D. Principles of Pharmacology: The Pathophysiologic Basis of Drug Therapy. 2008, Lippincott Williams & Wilkins.
- Rutter P. Community pharmacy: symptoms, diagnosis and treatment – second edition
- Koneti KK, Jones M, Management of acute pain, Surgery. 2016, In Press, Corrected Proof, not yet assigned to a volume/issue. dx.doi.org/10.1016/j.mpsur.2015.11.008
- Page P., Pathophysiology of Acute Exercise-Induced Muscular injury. Journal of Athletic Training. 1995, 30(1): 29-34.
- Hooten WM, Timming R, Belgrade M, Gaul J, Goertz M, Haake B, Myers C, Noonan MP, Owens J, Saeger L, Schweim K, Shteyman G, Walker N. Health Care Guideline: Assessment and Management 2of Chronic Pain. Institute for Clinical Systems Improvement. Sixth Edition, November 2013.
- Graven-Nielsen, T & Arendt-Nielsen, L. Assessment of mechanisms in localized and widespread musculoskeletal pain. Nat. Rev. Rheumatol. 2010, 6: 599–606.
- GSK Data on File 2011b
- Predel H G et al BMC Muskuloskeletal Disord 2013; 14: 250
Product information
Voltarol Pain-eze Emulgel®, Voltarol® 12 Hour Emulgel® P 2.32% Gel (diclofenac diethylammonium). Indications Local symptomatic relief of pain and inflammation in: trauma of the tendons, ligaments, muscles and joints, e.g. due to sprains, strains and bruises; localised forms of soft tissue rheumatism. Dosage and method of use Adults and children aged 14 years and over. Gently rub 2-4 g into skin of affected site. If symptoms worsen or do not improve within 7 days, seek medical advice. Pain-eze Emulgel: Apply 3-4 times daily for up to 7 days. Leave at least 4 hours between applications. No more than 4 applications in 24 hours. Maximum daily dose 16 g. Not for use for longer than 7 days unless recommended by doctor. 12 Hour Emulgel P: Apply 2 times daily (morning and evening) for up to 14 days. Maximum daily dose 8 g. Not for use for longer than 14 days unless recommended by doctor. Contraindications Patients whose attacks of asthma, urticaria or acute rhinitis are precipitated by aspirin or other NSAIDs. Hypersensitivity to diclofenac, aspirin, other NSAIDs or excipients. Third trimester of pregnancy. Concomitant use of other diclofenac products or oral NSAIDS. Children under 14 years. Precautions Apply only to intact, non-diseased skin. Do not use with occlusion. Avoid ingestion or contact with eyes or mucous membranes. Caution in patients with previous or active peptic ulceration or suffering from/previous bronchial asthma. Avoid excessive exposure to sunlight. May cause mild localised skin irritation. Discontinue use if skin rash develops. Pain-eze Emulgel: Suffering from/history of asthma or allergic disease. Side effects See SPC for full details. Rash, erythema, pruritus, dermatitis, eczema. Hypersensitivity (including urticaria), angioneurotic oedema. Asthma. Photosensitivity reactions. Product licence number, legal category, pack size and RSP (excl. VAT) Pain-eze Emulgel: PL 44673/0156 (GSL) 30 g £4.49, 50 g £6.54, 100 g £10.71. 12 Hour Emulgel P: PL 44673/0154 (P), 30 g £5.83, 50 g £8.33, 100 g £14.99. PL holder GlaxoSmithKline Consumer Healthcare (UK) Trading Limited, 980 Great West Road, Brentford, Middlesex, TW8 9GS, UK. Date of preparation October 2016.
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