PF1011 Pharmacy Practice I Pain and Analgesia – Part 2 PDF

PF1011: Pharmacy Practice I Pain and Analgesia – Part 2 Dr. Harriet Bennett-Lenane [email protected] Lecture Layout Pain and Analgesia – Part 2 Muscular Injuries Back Pain Period Pain Headaches Tension Headache Migraine Medicine Overuse He...

PF1011: Pharmacy Practice I Pain and Analgesia – Part 2 Dr. Harriet Bennett-Lenane [email protected] Lecture Layout Pain and Analgesia – Part 2 Muscular Injuries Back Pain Period Pain Headaches Tension Headache Migraine Medicine Overuse Headache Aims and Objectives For each type of pain: Detail the aetiology Identify important considerations specific to its presentation and management Be aware of the OTC treatment options for patients with these symptoms, and understand their safe and effective use Know when referral for further medical attention is required. WWHAM Questioning Method Who is the patient? What are the symptoms? How long have the symptoms been present? Action taken? Medication being taken? Muscular (Soft-Tissue) Injury Specific Things to Consider Presenting symptoms which may warrant referral: Swelling Bruising Severe pain Nature of the injury? Higher impact force → fracture Sudden onset after single traumatic event → tendon (muscle to bone) or ligament (bone to bone) tear Unable to bear weight on foot/ankle/leg → refer Muscular (Soft-Tissue) Injury Range of motion Nature of pain Referred pain suggests nerve root compression Pain insidious in onset and progressive more likely to be a degenerative disease Age of patient Children: greenstick fractures Elderly: osteoporosis, osteoarthritis Muscular (Soft-Tissue) Injury Referral Required Immediate swelling and severe pain Children under 12 and elderly patients Shoulder - decreased range of motion in all directions Ankle/foot - unable to bear any weight Suspected fracture Treatment failure Muscular (Soft-Tissue) Injury Treatment Advice PRICE Protect Rest Ice Compression Elevate Simple analgesia (see Part 1) Topical products (see Part 1) Muscular (Soft-Tissue) Injury Other products: Epsom Salts (magnesium sulfate) or gel Bruising Bleeding under the skin Ruptured blood vessels Skin discolouration - Initially red/pink gradually becoming blue green and yellow Arnica Often claimed to help reduce bruising and even inflammation Studies show unlikely to have a clinically significant effect (similar to placebo) Small benefit has been seen in small studies from topical arnica Beware unexplained bruising → refer Back Pain Cervical Thoracic Lumbar Lower back pain Sacral Back Pain Specific Things to Consider Age of Patient: Under 15 years – higher incidence of potentially serious causes → refer (unless sports or schoolbag related) 15-30 years – prolapsed disc, trauma, fractures, pregnancy, ankylosing spondylitis 30 to 50 years – osteoarthritis, prolapsed disc and malignancy Older than 50 years – increased risk of osteoporosis, malignancy and metabolic bone disorders Back Pain Specific things to consider Location Radiation e.g. sciatica → refer Evidence of trauma Effect on mobility Factors which aggravate or relieve pain Onset – acute, sudden onset mostly muscle strain. Refer in elderly. Refer insidious onset. Back Pain Referral Required Young or older patients Chronic back pain (>6 weeks) Pain that radiates away from lower back Pain above the lumber region Persistent and progressively worsening pain Failure of symptoms to improve after 4 weeks Fever Weight loss Feeling unwell Numbness Incontinence Back Pain Treatment Advice Simple analgesia Refer if no improvement after 7-10 days Topical products NSAIDs, Rubefaciants Hot and cold compress Bed rest - possibly counter-productive Little to no evidence for: Glucosamine Chondroitin Arnica Period Pain (Primary Dysmenorrhoea) Menarche to menopause Cycle typically lasts 28 days – shorter or longer. Menstruation 3-7 days Dysmenorrhoea Primary (PD) Secondary (endometriosis) Affects over 50% of women 7-15% severe cases Overproduction of uterine prostaglandins E2 and F2-alpha Causes painful cramps Primary Dysmenorrhoea Symptoms Cramping pain shortly before onset of bleeding, lasting for 2-3 days. Associated with some or all of: fatigue, back pain, nausea, vomiting and diarrhoea Associated with younger women who have recently started having periods Note: anovulatory cycles are usually painless. Primary Dysmenorrhoea Specific Things to Consider Age PD is common in adolescents and women in their twenties Nature of pain Cramping or dull, continuous diffuse pain? Severity Pain rarely severe in PD Severity decreases with onset of menses Onset of pain PD starts shortly before (6 hours) or within 24 hours of menses Rarely lasts for more than 3 days Primary Dysmenorrhoea Referral Required Heavy or unexplained bleeding Pain experienced before menses Pain that increases at the onset of menses Signs of systemic infection (e.g. fever, malaise) Vaginal bleeding in postmenopausal women Women over the age of thirty with new or worsening symptoms Severe or disabling symptoms Primary Dysmenorrhoea Treatment Advice NSAIDs Very effective in 80-85% of women. Little evidence of superiority of any particular NSAID. Some NSAIDs on prescription (mefenamic acid) are commonly prescribed for 2 days before expected menses onset and first 3 days of menses. Hyoscine Butylbromide – antispasmodic (licensed for spasm of gastrointestinal tract). Little evidence for increased effect over placebo, but anecdotally can be effective. Paracetamol (also not anti-inflammatory, so may not be very effective) Hot Water Bottle Vitamin E, B1 and B6 Headache Headache A “headache” is not enough information for accurate diagnosis and treatment. For the “What are the symptoms” part of WWHAM, your findings must be much more specific. Important Questions About Symptoms Onset of headache? Frequency and timing? Location of pain? Severity of pain? Triggers? Attack duration? Associated symptoms? Headaches in Community Pharmacy Paul Rutter. Community pharmacy: symptoms, diagnosis and treatment. 4th Edition. Elsevier: Edinburgh Headache Referral Required Headache in children under 12 with a stiff neck/rash Headache after recent trauma injury Nausea/vomiting in absence of migraine symptoms Neurological symptoms New or severe headache in people over 50 years Progressive worsening of headache symptoms over time Very sudden and/or severe onset of headache Headaches unresponsive to simple analgesics Headache lasting more than two weeks. Tension Headache Symptoms Bilateral Pain over top of head ‘Band around the head’ ‘Weight pressing down’ Non-pulsating Gradual onset, worsens over time 4 times as many women as men Triggers Mental stress Secondary to physical stress Alcohol use Eye strain Caffeine Fatigue Excessive smoking Dental problem Tension Headache Treatment Advice Simple Analgesics Codeine Products X Heat e.g. microwavable bags Exercise or other de-stressors Headache Diary Triggers Massage Biofeedback Acupuncture Cognitive behavioral feedback Adequate hydration Migraine Symptoms One sided (unilateral) Severe Throbbing Lasts 4-72 hours Nausea (almost all); vomiting (1/3) Preceded by aura in 20% of cases Nausea, vomiting Visual disturbances (90% of auras) Sensitivity to light, noise, movement Triggers Stress Environmental Dietary (only 20%) Hormonal Drugs Physical Emotional Migraine Specific questions to ask Do you get headaches accompanied by nausea or vomiting? Is your headache severe or throbbing and usually on one side of your head (not always the same side)? Does bright light hurt your eyes during an attack? Do you become particularly sensitive to loud sounds and/or smells? Does your headache reduce your ability to work, study or socialise? If the answer is yes to two or more of these questions then the patient may have migraine Migraine Treatment Simple Analgesia Paracetamol Ibuprofen Excedrin® - 250 mg Aspirin, 250 mg Paracetamol, 65 mg caffeine Codeine-Containing Products (Nurofen Plus®, Solpadeine®) Migraleve® Pink tablet: paracetamol, codeine, buclizine Yellow tablet: paracetamol, codeine. Sumatriptan Pharmacist Consultation Sumatriptan Deregulated to pharmacy OTC status in October 2018. 50mg tablets. Strict suitability criteria, which the pharmacist must assess before supplying. Storage in Pharmacy. Sources of Guidance Product SPC Pharmaceutical Society of Ireland Manufacturer's Guidance Consultation Aid Questions Sumatriptan Mode of action Part of the family of “triptans” Triptans are 5HT1 agonists, and stimulate 5HT1B and 5HT1D receptors. Triptans act in the following ways: cause constriction of the cranial blood vessels stop the release of inflammatory neurotransmitters reduce pain signal transmission Sumatriptan (Sumatran Relief) Indication Acute treatment of Prior migraine migraine (+/- aura) diagnosis Mode of action Serotonin 1 receptor Vasoconstriction agonist (5HT1D, Reduces pain signal ?5HT1B) transmission Dose (18-65 50mg at onset of first Max. 100mg in 24 only) sign of migraine hours. At least 2 hours between doses. Side-effects Dizziness, drowsiness, Common flushing, nausea, vomiting, heaviness, myalgia, pain, tightness, weakness Overdose As per side effects Supportive treatment Monitor for at least 10 hours Sumatriptan Requirements for OTC Supply: Pharmacist Supply Only - Assessed for risk of safe and appropriate as cardiovascular events/IHD. per SPC. Heavy smokers, women with migraine who are taking the combined oral contraceptive Adults aged 18- 65 years pill, hypercholesterolaemia, marked obesity, diabetes or a family history of early Acute treatment of heart disease. migraine – not Post menopausal women prophylaxis. and males >40 w/ risk Simple analgesics tried factors: hypercholesterolaemia, regular and ineffective. smoking, marked obesity, diabetes or a family history of early heart disease (father/brother Migraine previously developed HD10days/month, >4/month, first ever migraine within last 12 months. Pregnant/Breast Feeding. Taking medications mentioned in C/I. Medication Overuse Headache. Women on COC → if migraine onset within previous 3 months, are worsening or migraine with aura. Pattern of symptoms changed or attacks more frequent, more persistent, more severe. Patients who do not recover completely between attacks. Following administration can be associated with transient symptoms (chest pain and tightness) - where such symptoms are thought to indicate ischaemic heart disease: No further doses of sumatriptan should be given. Medical evaluation should be obtained immediately.  Medication Overuse Headache Prolonged use of any type of painkiller for headaches can make them worse. Medication overuse headache is defined as headache occurring on 15 or more days per month developing as a consequence of regular use of headache medication for more than three months. ≥ 15 days/month of simple analgesics (such as paracetamol, ibuprofen, aspirin) or ≥ 10 days/month of ergotamine, 5HT1 agonist (‘triptan’), opioids or combination analgesics. Requires referral to the doctor to begin addressing the issue.