Pharmacists in pain

The pathophysiology of pain is still poorly understood by a great many front line healthcare workers and one the results of this is that analgesics are still being prescribed on a prn (when required) basis for moderate–severe pain. This was one of the messages from Arthur Lipman (Professor of Pharmacotherapy, University of Utah, USA), the keynote speaker at HPE LIVE.

Pain is, in many ways, a universal language. It is not confined to one particular medical specialty; it crops up in most areas. Pain is such a common finding that for many years experts in the field of pain have said that it should be regarded as the fifth vital sign. Others have argued that freedom from pain should be a basic human right, limited only by our ability to achieve it. Pain colours the sufferer’s view of life and it has profound, far-reaching physiological effects. Among other things, it suppresses natural killer cell activity and therefore alters immune function. In addition to a complex array of physical effects, it also has serious psychological effects including anxiety, depression, sleep deprivation and thoughts of suicide.

A great deal is known about pain and about the effective use of analgesics, and yet we continue to use them in ineffective, and sometimes dangerous, ways. Professor Lipman acknowledged that relatively few pharmacists have chosen to specialise in pain management. However, many pharmacists have the opportunity to optimise analgesic regimens in the course of their work in other specialties. Even if we only took a few small steps in this direction, it could make a profound difference to patients. For example, adopting a zero-tolerance attitude to prn analgesics for ongoing pain, such as cancer pain, would clearly be a good start. This would have to go hand-in-hand with a drive to educate other health care staff about effective analgesic use and meaningful, helpful explanations for patients. Another useful step would be to eliminate the use of the intramuscular route of administration for analgesics for post-operative patients. All other routes are preferable because they offer better pharmacokinetic profiles or less pain on administration or both.

Professor Lipman pointed out many other areas where a good understanding of pharmacotherapy of pain and a willingness to put it into practice is important. Pharmacists already have a good knowledge of the basic pharmacology of analgesics and the issues concerned with safe administration. The challenge to pharmacists was clear and the answer is equally clear.

A further illustration of the importance of safe analgesic administration was presented at another recent meeting (see page 8, Braun IV meeting). Gillian Cavell explained how ‘misplaced familiarity’ had led to the deaths of at least two adult patients after intravenous paracetamol administration. Paracetamol is widely perceived to be a commonly-used, harmless drug. When the standard 1000mg dose is given to adults, there is a danger that small adults could receive a staggered overdose. This is less well-recognised than the position with children, where many patients require less than one tenth of the contents of a standard container. Truly, an accident waiting to happen – and an opportunity for pharmacists to work with the pharmaceutical industry to produce a safer presentation.

Safe and effective use of analgesics is something to which all pharmacists should be committed in thought, word and deed. After all, to use a well-worn expression: “If not us, who? If not now, when?”