September Is Pain Awareness Month

Pain comes in all shapes and sizes, located anywhere from your head to your toes. Pain can be acute, lasting less than 3 to 6 months, in which the cause is usually identifiable, such as surgery or trauma. The underlying cause of pain that persists to a chronic form may be more difficult to identify and is often a result of nerve dysfunction.¹

This September is Pain Awareness Month, and pharmacists are sitting at the front lines eager to combat it. When patients experience pain, they may find themselves running to the store to grab the cheapest bottle of pain relievers from the shelf, but when patients arrive at the pharmacy, there are multitudes of options. Should you get a tablet, capsule, or gel? Pharmacists are best suited to help patients sort through these choices.

Aside from managing side effect profiles of certain medications, pharmacists also consider how the drug prescribed will affect organ function, have potential for drug interactions, food interactions, and alterations in lab values. These are topics of the drug selection process that may not have been mentioned to patients by other health care providers, but an easily-accessible and knowledgeable pharmacist will monitor these areas of focus with every prescription or OTC medication to ensure the patient’s safety.

Patients may not realize the impact that a pharmacist can have on helping them manage pain. The pharmacist’s first step is to determine what is causing pain and if there are any medical conditions that would prevent using certain pain medications. They may ask questions about the pain such as location, severity, how long it’s been occurring, and its impact of daily life, while screening the patient for any history of cardiovascular disease, liver disease, or stomach ulcers.^{1, 2} Once the pharmacist knows a little more about the pain, they can then recommend a non-pharmacologic therapy like light exercise, heat/cold application, or over-the-counter products, such as the commonly known pain relievers acetaminophen (Tylenol), naproxen (Aleve), ibuprofen (Advil), or aspirin for patients with mild to moderate pain.¹ Additionally, pharmacists are able to manage prescription pain medications and opioid therapies for more severe or chronic pain to ensure safety as well.

Acetaminophen (Tylenol), is a good first choice in treating mild-to-moderate acute pain because it is tolerated well and has few interactions with other medications patients may be prescribed.^{3, 4} Acetaminophen has analgesic and antipyretic effects with weak anti-inflammatory effects. Acetaminophen is a good option if patients have history of ulcers, allergies to aspirin, or even a child with a fever. However, patients should be aware that acetaminophen could cause serious liver toxicities. Patients should not exceed 4000 mg of acetaminophen daily. An even lower dose is recommended for chronic alcoholics, so a pharmacist may ask about alcohol consumption to avoid possible liver side effects.⁴

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, are also effective at treating mild-to-moderate pain but they can reduce inflammation due to their analgesic, antipyretic, and anti-inflammatory abilities.⁴ NSAIDs are associated with risk of causing stomach bleeding and ulcers. Some risk factors pharmacists may look for prior to recommending a NSAID include history of stomach bleeding or ulcers, age, cardiovascular disease, smoking and alcohol use, and possible duration of therapy before they can comfortably recommend this pain reliever. ^3,4

Additionally, pharmacists are able to interpret labs of those patients taking NSAIDs to assess their organ functions, such as, BUN or serum creatinine for their kidneys.⁵ Several NSAIDs, like ketorolac (Toradol), are contraindicated in patients with poor kidney function, which pharmacists monitor in each patient to assess the appropriateness of the agents. ^3,5 An example would be patients using NSAIDs, while taking blood pressure medications like lisinopril or losartan. These two agents, when used with NSAIDs, could reverse the effects of the blood pressure effects and could ultimately cause kidney damage over time.⁴

Aspirin, the first and oldest anti-inflammatory agent, has been utilized since ancient Sumerian and Egyptian times from willow.⁶ Like other NSAIDs, aspirin can treat mild-to-moderate pain and inflammation; however, aspirin is still likely to cause stomach bleeding and ulcers.⁴ Pharmacists will instruct patients to make sure to take NSAIDs with food to help reduce the potential for stomach bleeds and ulcers. Additionally, aspirin is utilized for its ability to inhibit platelets in the body, which grants a cardioprotective effect by thinning the blood. ^3,4

Pharmacists are screening for major drug interactions that can lead to a serious bleed if a patient is taking NSAIDs. An example is if a patient is taking warfarin (Coumadin) and NSAIDs together. They may be at a higher chance of seeing a serious bleed and the pharmacist will recommend another agent to lower the risks.⁴ Another example of a drug interaction includes patients taking Brilinta (ticagrelor), a new antiplatelet agent, with aspirin at a dose higher than 100 mg. Pharmacists know their patient is at a greater risk for blood clots because the higher doses of aspirin will decrease the effects Brilinta has on the blood. The pharmacist will guide these patients toward another agent to treat their pain in order to avoid these serious events. ⁵

Pharmacists are often more accessible than other healthcare providers. As a result, they are in the position to form strong, trusting relationships with long-term patients that helps ensure more appropriate pain management and control.²

Written with Christopher Squires PharmD Candidate 2018 Harrison School of Pharmacy Auburn University.

References:

1. Herndon CM, Strickland JM, and Ray JB. Pain Management. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e. New York, NY: McGraw-Hill; 2017. Chapter 60.

2. Tanzi MG. Pain management 101 for pharmacists. Pharmacy Today. 2015 September. [cited 2017 August 10]; 21(9):66. Available from: http://www.pharmacytoday.org/article/S1042-0991(15)30174-2/fulltex

3. Blondell RD, Azadfard M, and Wisniewski AM. Pharmacologic therapy for acute pain. Am Fam Physician [Internet]. 2013 Jun 1 [cited 2017 Aug 10];87(11):766-772. Available from: http://www.aafp.org/afp/2013/0601/p766.html

4. Glosser T, Smyth E, and FitzGerald GA. Pharmacotherapy of inflammation, fever, pain, and gout. Anti-inflammatory, antipyretic, and analgesic agents; Pharmacotherapy of Gout. In: Hilal-Dandan R, Brunton LL. eds. Goodman and Gilman's: The Pharmacological Basis of Therapeutics, 12e. New York, NY: McGraw-Hill; 2011. Chapter 34.

5. Ticagrelor, Toradol. In: Lexi-Comp Online [AUHSOP Intranet]. Hudson, OH: Lexi-Comp/Wolters Kluwer Health. [cited 2017 Sept 9]. Available from http://online.lexi.com/action/home.

6. Connelly D. A history of aspirin. Clinical Pharmacist [Internet]. 2014 Sept [cited 2017 Aug 10];6(7). Available from: http://www.pharmaceutical-journal.com/news-and-analysis/infographics/a-history-of-aspirin/20066661.article