OTC pain management in the community Module B32PAI Tony Shaw
OTC pain management in the community
Module B32PAI
Tony Shaw
Analgesics
• Used to alleviate aches and pains • OTC oral analgesics • NSAIDS and Aspirin – Aspirin – Ibuprofen – Diclofenac – Naproxen
• Paracetamol • Combinations containing the above • Topical analgesics
NSAIDS and Aspirin
• Part of a group of drugs called NSAIDs – Non-‐steroidal anC-‐inflammatory agents
• Act by blocking prostaglandin synthesis • Analgesic and anCpyreCc • Licensed for mild to moderate pain from a wide range of causes and as anCpyreCc
NSAIDS and Aspirin
• Side-‐effects – Gastric irritaCon and bleeding
• CauCons – Asthma – may precipitate aKacks – Renal and hepaCc disease (so elderly) – Pregnancy, parCcularly 1st and 3rd trimesters
NSAIDS and Aspirin
• ContraindicaCons – Current or history of ulcers or gastric problems – Aspirin in children under 16
• InteracCons include: – Aspirin – Warfarin and Methotrexate – Ibuprofen – Lithium and DiureCcs
Aspirin
Ibuprofen
OTC supply Adult
• Should be taken with or just aVer food or a meal (label 21)
On prescrip/on Adult
• Should be taken with or just aVer food or a meal (label 21)
Diclofenac Potassium
Diclofenac Potassium
Naproxen 250mg tablets
Paracetamol
CombinaCon products
• Codeine / Dihydrocodeine – Mild opiates not thought to increase the efficacy significantly
– Side-‐effects include consCpaCon, dizziness • Caffeine – Evidence is not conclusive but not thought to have much effect
– Less caffeine than in a cup of tea or coffee • But these products tend to be more expensive!
Topical preparaCons
• NSAIDs – Short-‐term use (<2 weeks) – Can have systemic effects and side-‐effects
• Rubefacients – Salicylates (aspirin cauCons apply) – NicoCnates
Pain assessment
• Can’t measure or see • Need to rely on paCent’s report – LocaCon – DuraCon – Severity – Recurrence
• Also need to check for accompanying symptoms
Common painful condiCons
Back Pain
• SoV Cssue injury: strain of spinal muscles and ligaments e.g. lumbago and fibromyalgia – twisCng or liVing
• The pain may spread right across the back along the level of the top of the pelvic girdle or verCcally on one side of the spine
• Pain may radiate to buKock or thigh, restricCng movement and causing paCent to adopt a posture leaning forward or to one side
• PaCent is otherwise well – 90% of acute aKacks usually resolved in six weeks
NHS choices
Back Pain
• Trapping of nerve root, usually sciaCc nerve, due to slipped vertebral disc (sciaCca) • felt in lower back and oVen radiates down one leg, someCmes as far as foot
• Pain can be intense and burning • Pain is constant and made worse by movement • PaCent limps and unable to flex the hip very far making signg and climbing stairs uncomfortable
• gait is sCff and awkward • PaCents hold themselves rigid to avoid movement
Back Pain Treatment
Back Pain Refer if • Backache not related to movement • Upper back pain not obviously due to muscle or ligament
strain • Associated with other symptoms of illness • Associated with neurological symptoms eg Cngling or
numbness in legs or feet • Bowel or bladder funcCon problems • Severe pain at night • Cyclical low-‐back pain in middle to second half of menstrual
cycle • Unresponsive to 7 day treatment with OTC products
Injuries
Injuries Refer if • Severe pain • Severe swelling • Numbness • Limb unable to bear weight • Limb, hand, foot of digit is immobilised • Pain/ache in old injury • Swelling occurs in old injury • Joint feels abnormal or unstable
Injuries Treatment
Dental Pain
Dental Pain
• Caused by inflammaCon of pulp or peridontal membrane of a tooth – Rich nerve supply in both structures – Impulse sent to cerebral cortex – pain perceived
• Not self limiCng – requires referral in all cases
• Analgesics give symptomaCc relief unCl dental assessment and treatment available
Headache
• Tension
• Vascular
• TracCon
Tension Headache
– Pericranial muscle contracCon – Psychogenic origin – Pain is oVen at base of skull but can be over top of head to eyes – Bilateral (frontal/occipital) – Dull pain, can be described as a band – Can last a few hours to several days – Triggerred by tension, anxiety and faCgue – Most common cause of headache
Chronic Daily Headache
• Occurs at least 15 days of the month • It lasts at least four hours each episode • Seems to be present from morning to night • Ache or dull throbbing pain • PaCents taking simple or combinaCon pain relief on more than three days a week
Vascular Headache
• DilataCon or constricCon of blood vessels in brain and cranium
• Headache associated with febrile illness – Caused by vasodilataCon
• Migraine is vascular in origin – Neurochemical pathology also involved
Migraine
Migraine
• AKacks lasCng 4 to 72 hours • At least two of: – Throbbing or pulsaCng pain – Moderate to severe intensity pain – Unilateral pain – Pain aggravated by movement
• At least one of: – Nausea and / or vomiCng – Photophobia and phonophobia
• Can have aura symptoms before pain
Migraine
• Recurrent – Associated with menstrual cycle – May occur at regular Cmes e.g. Weekends
• Triggered by certain foods
• Triggered by stress
Treatment
Cluster Headache
• Largely affects men aged 40 to 60 years • Lasts 10 minutes to 3 hours • Usually occurs same Cme of day • 50% of sufferers experience night Cme symptoms
• Steady intense unilateral orbital boring pain • Refer
TracCon headache
• InflammaCon or compression of brain – MeningiCs – EncephaliCs – Haematomas (including head injury related) – Tumours – Cerebral abscesses
DifferenCal diagnosis
• Eye strain – Spasm/faCgue of ciliary and periorbital muscles of eye
• Glaucoma • Neuropathic pain from shingles • Temporal arteriCs – Almost exclusively in the elderly
• Referred pain from jaw • Muscle strain and pulled ligaments in neck or upper back
Headache red flags
• Refer if: – Sudden onset ‘first’ headache – ‘worst ever headache’ (may be Subarachnoid haemorrhage)
– Late onset new headache (> 40 years) – Headache with sCff neck – Headache with sCff neck or rash in under 12’s – Progressively increasing headache – Headache with drowsiness, unsteadiness, visual disturbances or vomiCng
Recommended texts
• Non-‐PrescripCon Medicines • Alan Nathan (4th edn, 2010)
• Managing Symptoms in the Pharmacy • Alan Nathan (Pharm press, FASTtrack)
• Symptoms in the Pharmacy • Alison Blenkinsopp, Paul Paxton, John Blenkinsopp (6th edn, 2009)
• Minor Illness or Major Disease? • Clive Edwards & Paul SCllman (4th edn, 2006)
• Community Pharmacy: Symptoms, Diagnosis and Treatment • Paul RuKer (2nd Edn, 2009)
• Symptoms, diagnosis and treatment : a guide for pharmacists and nurses • Paul RuKer
• BriCsh NaConal Formulary (BNF 66) • BriCsh AssociaCon for the Study of Headache (BASH) Guidelines 2007 • Electronic Medicines Compendium
• hKp://www.medicines.org.uk/ • Chemist & Druggist OTC Directory