PAIN of pain9 . Dose reduction is advised


in severe hepatic impairment as metabolism by the cytochrome p450 system leads to a build-up of toxic metabolites1


.


Non-steroidal anti-infl ammatory drugs are useful for pain and infl ammation and in addition they too are antipyretic. Patients show signifi cant differences in both tolerance and response to the various NSAIDs and so they should always be offered an alternative when the fi rst NSAID has proved ineffective. The gastrointestinal side effects of NSAIDs can be dangerous and even life-threatening in some cases1


. By giving a NSAID


with a low risk of gastrointestinal side effects at the lowest dose possible and with a co-prescribed gastro- protective agent, side effects can be kept to a minimum1


. All NSAIDs can cause


increased risk of stroke and heart attacks; ibuprofen is considered to be the safest drug.


COX-2 selective inhibitors have the advantage of inhibiting only the COX- 2 isoenzyme rather than both COX-1 and COX-2 as the NSAIDs do. By this mechanism of action, they are much less irritant to the gastrointestinal system. Despite this, they are known to have an increased risk of cardiovascular side effects over NSAIDs and so are contraindicated in patients


with established cardiovascular disease.


An opioid is a semi-synthetic or synthetic drug which acts at opioid receptor sites. Opioids should be recommended for moderate to severe pain in accordance with the WHO analgesic ladder. Although many healthcare professionals are hesitant to advise on the use of opioids due to the potential for addiction, tolerance and dependence, some patients have favourable outcomes over long periods of time when prescribed opioids. Patients must be advised as to the common side effects of opioids and must be made fully aware of their treatment plan before initiation of an opioid8


. Additionally, any patient just


beginning treatment with an opioid or undergoing an increase in dose should be advised to avoid driving until feeling fi t to drive1


. Specialist referral


is advised where problem drug use or tolerance develops.


Neuropathic pain rarely responds to the treatments within the WHO analgesic ladder. Gabapentin could be considered for the treatment of such pain, and pregabalin can be considered if fi rst and second line therapies are ineffective10


is long enough. Amitriptyline can be considered for fi bromyalgia and neuropathy.


The summary of the 2007 Cochrane review of antidepressants for neuropathic pain is as follows:


‘…..At least one third of patients with neuropathic pain who took traditional antidepressants (such as amitriptyline) obtained moderate pain relief or better. There is also evidence that Venlafaxine, a newer antidepressant, has similar effectiveness to traditional antidepressants. However, approximately one fi fth of those who take these medicines for pain discontinue the therapy due to adverse effects. There is very limited evidence that some other newer antidepressants, known as SSRIs, may be effective but more studies are needed to confi rm this. Neuropathic pain can be treated with antidepressants and the effect is independent of any effect on depression11


.” . A suffi cient


amount of time should be given when trialling an antiepileptic drug for neuropathy; generally one month


PAINMASTER


Painmaster uses micro current stimulation, which has been proven to provide far more effective pain relief than a traditional TENS device. Tens often only gives a temporary relief from pain, turn off TENS and the pain returns. Micro current stimulates the painful area using a similar electrical current as the body's own cellular structure, producing long-lasting and cumulative results and ultimately long term relief.


Order enquiries, TEL: 0844 381 4451 or email info@allergykids.co.uk


Both tricyclic antidepressants and anticonvulsants are the mainstay of neuropathic pain and can be used individually or in combination1


.


These medicines are often used off-license for chronic pain and the patient information leafl et can cause confusion in some patients, so pharmacists are in an ideal position to counsel on the appropriateness of these drugs for their condition.


Transcutaneous electrical nerve stimulation (TENS) is becoming increasingly popular as a form of analgesia because it has no systemic effects and is not expensive1. It works by providing continuous electrical stimulation to A nerve fi bres and in doing so inhibits the slower C nerve fi bres, reducing neuronal activity in the spinal cord1. TENS is not suitable for any patients with a pacemaker and should be used with extreme caution in those with epilepsy1


.


Topical analgesics are a popular choice with the obvious benefi t of reduced systemic effects. NICE guidance recommends the use of topical NSAIDs prior to initiating oral treatment in patients with osteoarthritis who have pain in their knees and hands1


. Other


topical preparations include Flexiseq for the treatment of osteoarthritis and Pernaton gel for the treatment of aches and pains associated with


22 - SCOTTISH PHARMACIST


wear and tear. Heat rubs provide relief of pain for some patients but should never be recommended within 48 hours of a strain or sprain injury as they can encourage swelling. Cooling sprays, rubs and plasters can be an appropriate alternative with a similar mode of action.


Acupuncture is recommended as a form of short term therapy in those with chronic low back pain and osteoarthritis.. Having been used routinely in Asia for many years, it is becoming more widely available in western society to treat migraine, visceral pain and musculoskeletal


REFERENCES


1. Wilson, E. 2009. Pain: treatment and management. 2009: Outset Publishing Ltd.


2. The British Pain Society. 2009. FAQs. [Online]. [Accessed 20/5/14]. Available online at: http://www.britishpainsociety. org/media_faq.htm


3. The Musculoskeletal Elf, Minervation Ltd. 2012. Cost-effectiveness of self- management for chronic pain in an aging population. [online]. [Accessed 20/5/14] Available online at: http:// www.themusculoskeletalelf.net/cost- effectiveness-of-self-management-for- chronic-pain-in-an-aging-population/


4. Bradford, E. 2014. NHS ‘failing’to meet targets over chronic pain care.[Online] [20/5/14] Available online at: http://www. bbc.co.uk/news/uk-scotland-glasgow- west-27159366


5. Healthcare Improvement Scotland. 2011. About us. [Online]. [Accessed 20/5/14] Available at:http://www. healthcareimprovementscotland.org/ about_us.aspx


6. Healthcare Improvement Scotland. 2014. Chronic Pain Services in Scotland: Where are we now? [Online]. [Accessed 19/5/14] Available at:fi le:///C:/Users/ Carla/Downloads/Chronic%20pain%20 services%20in%20Scotland%20April%20 2014%20V3%20(1).pdf


7. Tidy, C et al. 2014. Neuropathic Pain. [Online]. [Accessed 20/5/14]. Available at: http://www.patient.co.uk/ health/neuropathic-pain


8. NHS Quality Improvement Scotland. 2006. Management of Chronic Pain in Adults. [Online]. [Accessed 20/5/14]. Available at: fi le:///C:/Users/Carla/ Downloads/PAINCHRONIC_BPS_FEB06.pdf


9. NHS Choices. 2012. Painkillers, paracetamol. [Online]. [Accessed 20/5/14] Available at: http://www.nhs.uk/conditions/ painkillers-paracetamol/pages/introduction. aspx


10. Health Improvement Scotland. 2013. SIGN 136: Management of Chronic Pain. [Online]. [Accessed 20/5/14]. Available online at:http://www.sign.ac.uk/ pdf/qrg136.pdf


11. Saarto, T. and Wiffen, PJ. 2012. Antidepressants for treating Neuropathic pain. [Online]. [Accessed 20/5/14]. Available at:http://summaries. cochrane.org/CD005454/antidepressants- for-treating-neuropathic-pain


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