Family Practice Advance Access originally published online on August 17, 2005
Family Practice 2006 23(1):46-52; doi:10.1093/fampra/cmi068
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The use of medication for chronic pain in primary care, and the potential for intervention by a practice-based pharmacist
a Department of General Practice and Primary Care, University of Aberdeen and b Pain Management clinic, Aberdeen Royal Infirmary, Aberdeen, UK
Correspondence to Mrs M Elaine McDermott, Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen AB25 2AY, UK; Email: elaine.mcdermott{at}deveron.grampian.scot.nhs.uk
Received 27 September 2004; Accepted 20 June 2005.
McDermott ME, Smith BH, Elliott AM, Bond CM, Hannaford PC and Chambers WA. The use of medication for chronic pain in primary care, and the potential for intervention by a practice-based pharmacist. Family Practice 2006; 23: 46–52.
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Abstract |
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Background and Objectives. The majority of people with chronic pain use analgesics regularly. Ensuring their safe and appropriate use is important. This study aimed to describe patterns of analgesic prescribing in one general practice, devise a method of identifying chronic pain patients from prescribing records, and assess prescribing recommendations made after a pharmacist-led review of analgesic prescribing and identify the proportion of these acted on by GPs.
Methods. Prescribing records in a practice of 6720 patients were searched and 678 patients were identified as receiving prescriptions for analgesics. 230 were invited to participate and sent a questionnaire, including questions about chronic pain severity, general health and medications used. This was repeated after six months. The pharmacist completed a detailed medication review using information from medical records, questionnaires and personal interviews. Prescribing recommendations were made to GPs.
Results. 192 recommendations about safe or appropriate prescribing were made for 86% of participants after records review, 56% being directly related to analgesic use. After 6 months all recommendations had been implemented in 77% of the patients. Few additional recommendations were made after interview. There was little or no relationship with changes in chronic pain severity or general or psychological health.
Conclusions. We have demonstrated a method of identifying patients with chronic pain in primary care, and the feasibility and acceptability of a pharmacist-led intervention. This is of potential value in primary care, as relevant prescribing recommendations were made for most patients although further research is required to assess these.
Keywords. Chronic disease management: pain, pharmacy, prescribing.
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Introduction |
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Chronic pain is common in the community, affecting up to half of the population,1 with a wide-ranging impact on general physical, psychological and social health, and ability to work.2 Recovery from chronic pain is rare,3 its management is generally unsatisfactory, and it has been identified nationally as a priority area for clinical research.4,5 Primary care, where the majority of individuals with chronic pain present,6 is a key point of delivery of interventions to tackle the condition. A number of primary care-based interventions have been researched, including training of GPs in patient-centred management of chronic pain,7 nurse-led interventions8,9 and cognitive behavioural therapy.10,11 These have largely been intensive and costly, with mixed results.
Chronic pain is a multi-dimensional problem, requiring multi-dimensional management. The great majority of people with chronic pain use analgesics regularly.6 Thus, ensuring the safe and appropriate use of medication is an important part of the management of chronic pain, although not the only part. Clinical experience and previous research, however, suggests that analgesics are often prescribed sub-optimally,12 repeat prescriptions are often monitored imperfectly,13 and concomitant use of over-the-counter analgesia often occurs without reference to prescribed medicines including analgesics.14–16 These problems may lead to inefficient treatment of the pain, as well as increasing the risk of side effects.
Community pharmacists, with their expertise in drugs and therapeutics, and their contact with GPs and patients, are ideally placed to identify and address medicines-related problems in the management of chronic pain. Thus, they might review prescribed and over-the-counter medication of patients with chronic pain, exploring compliance and concordance, and advising them and their GPs of changes in dosage or treatments that might be more appropriate or beneficial. They might also highlight interactions between any prescribed or purchased medications, contributing to safer prescribing.
This paper describes a study to establish the potential value of a pharmacist-led intervention in managing chronic pain in primary care by assessing the number of prescribing recommendations made by a pharmacist in a group of patients taking medication for chronic pain and the proportion of these that are acted on by their GPs. The aims were to: describe patterns of analgesic prescribing in general practice; develop a means of identifying chronic pain patients through prescribing records; and test a pharmacist-led review of prescribing for chronic pain. The review used information from up to three sources: (i) patients' responses to a postal questionnaire; (ii) practice medical records; (iii) face-to-face interviews with the patient. An assessment of pain severity and general health was made before and after the study.
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Methods |
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The study was carried out in one general practice in Aberdeenshire, Scotland, with a practice population of 6720 patients and 4.5 principal GPs. The practice used the General Practice Administrative System for Scotland (GPASS) for almost all of its prescribing, including acute and repeat items. The study pharmacist was an established community pharmacist, based in the practice. The Grampian Research Ethics Committee approved the study.
Examination of prescribing patterns
With the aid of a Microsoft Access based Audit Tool (NIMROD), the GPASS prescribing records of adults aged 18 years or over were searched for all issues of prescriptions in the previous 120 days for analgesics and non-steroidal anti-inflammatory (NSAID) medications, in chapters 4.7 and 10.1.1 of the British National Formulary (BNF).17 Medications whose primary indication was migraine were not included in the search, nor were anti-epileptics or anti-depressants, which are sometimes used for analgesia, as we have previously shown that these drugs identify few additional people with chronic pain.18
The search included drugs issued as a result of surgery and related consultations (acute prescriptions) and those issued via the repeat prescribing system (chronic prescriptions). We identified all those who received two or more prescriptions for the selected medications in the 120 day period, and/or at least one chronic repeat prescription in the same period. This sample was likely to include a large proportion of individuals with chronic pain (defined by the International Association for the Study of Pain (IASP) as "pain that persists beyond normal tissue healing time, which is assumed to be 3 months").19
Study sample
Two groups of patients were identified as receiving prescriptions for chronic pain: those receiving repeat prescriptions, and those receiving acute prescriptions. (Some patients could be identified through both repeat and acute prescribing.) These patients were considered as the study population for the pharmacist review part of the study. A random sample of those receiving the selected analgesics by acute and chronic prescription was identified. The sample lists were screened by the patients' registered GPs, in order to exclude those whose participation in the study was thought to be inappropriate (for example in the case of severe mental or terminal illness). After these exclusions we aimed to have approximately 100 patients receiving acute and 100 receiving chronic prescriptions for chronic pain, to allow detailed review within the time available. Potential participants were sent: an information sheet describing the study; a form seeking signed consent to the three different parts of the study (returning the questionnaire only, review of medical notes by the pharmacist, and attendance at an interview with the pharmacist); and a postal questionnaire for completion. A reminder was sent after one month to non-respondents.
Questionnaire
The questionnaire included an assessment of chronic pain severity using the Chronic Pain Grade (CPG) questionnaire,20 which inquires about pain lasting more than three months and classifies its severity into five grades: 0 (no chronic pain), I (low disability, low intensity chronic pain), II (low disability, high intensity), III (high disability, moderately limiting), IV (high disability, severely limiting). The CPG is reliable and acceptable for use in self-completed postal questionnaires in the UK general population21 and is responsive to change over time.22 The questionnaire also included questions about sex and age of the respondent, and numerical rating scales for current general and psychological health. Respondents were also asked whether in the last twelve months they had attended: a GP, hospital specialist, physical therapist or alternative therapist for chronic pain; or used any medicines, including prescribed, non-prescribed and alternative medication. An identical follow-up questionnaire was posted to all patients six months after the notes review, or interview—see below.
Medical record reviews
The practice medical records of each consenting participant were examined for information about current regular painkillers and NSAIDs, their indication, and date of chronic pain diagnosis or initiation of treatment. Information was also collected on the use of any prescribed medications for pain in the previous five years, all other ‘active’ regular prescriptions, drug allergies, other healthcare professionals involved in the patient's care and any over-the-counter (OTC) medicine use recorded in the medical records and questionnaires. At the start of the study, treatment protocols had been agreed by all GPs for pain management, encompassing the efficacy and safety of medicines. These protocols were based on standard protocols, used both as teaching materials in pain management courses, and in clinical pain management practice which were adapted for the purpose of this study to provide a framework for the pharmacist's prescribing recommendations on pain therapy. The pharmacist made recommendations for changes of treatment on the basis of these protocols, to improve either the potential effectiveness or the safety of treatment. A record sheet was completed for each patient, including details of pain diagnoses and treatment, and any changes of treatment recommended. On completion, this was passed to the GP who signed it and retained it in the patient's records. Six months after the review, the medical records were reassessed to determine whether the recommendations had been accepted and implemented by the prescribing doctors.
Patient interviews
A random sub-sample of approximately 25% of patients was identified and invited to be interviewed by the pharmacist in the practice. The interview supplied information about: each drug used, its formulation, date started, dose and quantity last prescribed or purchased; their knowledge of the indication for the medicine; any side-effects experienced; how happy they were with the medication overall. From this information the pharmacist then determined the appropriateness of the medicine and the dose, the compliance, the degree of symptom control, and any side effects or monitoring required. The resultant record was then passed to the GP with any recommendations, signed and placed in the notes.
Data analysis
The questionnaire responses were entered into a Microsoft Access database and analysed using the SPSS for Windows statistical package. Descriptive statistics, including frequencies and crosstabs, were used to determine patterns of analgesic use in the practice, consulting patterns the distribution of general health and pain severity (CPG), and outcomes of the intervention.
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Results |
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Of the 6720 individuals registered with the practice, 678 (10.1%) were identified as receiving active medication for chronic pain (Fig. 1). Some overlap between searches was found, with some individuals identified twice or more (Fig. 2). Of the 230 questionnaires sent, 140 were returned completed (60.9%). There was no significant difference between respondents and non-respondents in either gender (x2 = 0.76, P = 0.38) or age-group (x2 = 0.20, P = 0.65). Characteristics of respondents are shown in Table 1. All but three respondents reported chronic pain of at least grade I severity. Eight patients returned the questionnaire only with no consent to review by the pharmacist, so 132 reviews were undertaken.
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Medications used
Twenty different prescription medicines for pain were identified at records review. In addition, questionnaire reports described the use of five non-prescription and seven alternative medicines. The most common prescription medicines used were paracetamol plus dextropropoxyphene, paracetamol plus dihydrocodeine, tramadol, paracetamol plus codeine, diclofenac, rofecoxib and topical NSAIDs. The non-prescription medicines reported were paracetamol, ibuprofen, topical preparations and combination analgesic medicines. The most popular alternative medicines were glucosamine and fish oils.
Recommendations based on questionnaire and records review
Recommendations could be made by the pharmacist for several reasons (Table 2): if no medication review by a GP was documented in the previous year it was considered ‘overdue’; if the potential effectiveness of current medication was considered sub-optimal, or its indication unknown, GP review was considered ‘desirable’; sub-optimal prescribing was identified on the basis of potential drug interactions, incomplete monitoring, and the potential for more effective treatment (with a change of either dose or medication). After records review by the pharmacist a total of 192 recommendations were made for 113 patients (85.6% of all patients assessed) (Table 2). Of these, 107 (55.7%) recommendations related directly to analgesic use. The number of different recommendations per patient ranged from one to four. Nine patients (8.0%) had a total of 13 recommendations made based on information from the questionnaire only, 76 patients (67.2%) had 119 recommendations from records review only.
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Twenty-eight patients (24.8%) had 60 recommendations made based on a combination of information from records review and questionnaire. Of these, the same 26 recommendations (43.3%) were apparent from both sources independently and 34 (56.7%) were based on information from both sources combined. In the latter group, additional information obtained from the questionnaire included: pain that was poorly controlled although this was not apparent from prescription requests or notes (21 patients); differences between GP records for current prescribed medication and that stated by patients (5 patients); and OTC medications being taken with potential to cause serious interactions with prescribed or other OTC medications (5 patients). According to the medical records after six months, recommendations had fully been carried out in 77.0% of patients (87/113), partially completed in 8.8% (10/113), and not implemented at all in 14.2% (16/113).
Recommendations based on interviews
Thirty-three patients were invited for interview, and 23 attended (69.7%). A total of 11 additional recommendations were made, for nine individuals as a result of these interviews. Four were made for 2 patients who after the first two stages had no recommendations made. One patient was experiencing side effects from prescribed medication and one had a condition which was not being adequately controlled by present medication although neither of these was related to their analgesic use or pain control. Of the other 7 patients, two stated that their pain control was inadequate, 2 stated that their medication records were not accurate, 1 required information on timing of drug dosage to increase efficacy and 2 required monitoring which had become overdue since notes review. At six-month follow up, all but two of these individuals were found to have had these additional recommendations implemented.
Follow-up questionnaire
All 140 individuals who returned the baseline questionnaire were sent a six-month follow-up questionnaire, of which 95 returned completed questionnaires (67.9%). Four of these had not consented to pharmacist review at the outset and were excluded from further analysis as part of this study. Of the others, 81 had had recommendations made by the pharmacist: the change from baseline in their mean score for current general health was –0.06 (median change –1.00) and for current psychological health +0.04 (median change 0.00). Since baseline, 18 had progressed to a more severe CPG, 20 to milder grade, 29 maintained the same grade, and there were 14 incomplete responses to the CPG questionnaire at baseline or follow up. The remaining 10 follow-up respondents had had no recommendations made: their mean change from baseline scores were –0.23 (median change –1.00) for current general health and +0.55 for current psychological health (median change +2.00). One reported a more severe CPG, five a milder grade, two the same and there were two incomplete responses.
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Discussion |
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In summary, we have demonstrated a means of identifying patients receiving analgesic prescriptions and described the patterns of analgesic prescribing in one GP practice. We have demonstrated the feasibility of a pharmacist-led intervention for chronic pain in primary care. This may be suitable for future research.
The pharmacist made recommendations in 85.6% of all patients reviewed, and 77.0% of these patients had had all recommendations executed after six months. The information provided by review of the GP-held medical records proved most useful in formulating recommendations. However, collecting patient's views from the questionnaires provided both useful and essential information, and in some instances potential serious problems were highlighted and acted upon. On the other hand, a face-to-face interview did not provide a great deal of added information regarding pain medication but it offered the patient the opportunity to discuss all aspects of their medication with the pharmacist. We have therefore confirmed the potential value of a pharmacist-led intervention in chronic pain in primary care, and suggested that this intervention should comprise prescribing recommendations after medical records review and patient questionnaire. Further evaluation by RCT would be appropriate.
Although this has been a small study in a single GP practice we have shown that patients for a potential trial can be identified easily, and the method used has proved to be feasible, and useful. This is based on a previously validated method,18 and, although of unknown sensitivity, it appears to be reasonably specific given that all but 2.5% of questionnaire respondents reported chronic pain of at least CPG I severity. Approximately 57% of patients approached agreed to take part in the questionnaire and medical records review.
In previous studies in primary care, consultations between elderly patients and a pharmacist were shown to be efficient and lead to significant changes in patients' drugs.23,24 These were not specific to chronic pain and they did not compare the effectiveness of a consultation-based medication review with a review based solely on the medical records. Other, less rigorous studies in chronic pain have suggested that pharmacist review may be valuable25,26 but these have been few, and not specific to primary care. This is therefore an important area for further research. A pharmacist-led intervention might complement other interventions such as nurse-led clinics,8,9 which also need further evaluation. In the UK, the introduction of supplementary prescribing (by pharmacists or nurses),27 enhanced by more sophisticated IT links between community pharmacies and GP practices28,29 may further enhance the efficiency of interventions such as this.
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Declaration |
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Funding: the study was funded by a research grant and sabbatical funding (MEMcD) from Grampian Primary Care NHS Trust. MEMcD also received a training grant from Pharmacia. BS is supported by an NHS R&D Primary Care Career Scientist Award, funded by the Scottish Executive Health Department.
Ethical approval: from the Grampian Research Ethics Committee.
Conflicts of interest: none.
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Acknowledgments |
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We are grateful to the GPs, staff and patients at Deveron Medical Practice, Banff, for their contribution to this research.
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References |
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