Urgent need to boost HMRs in patients with chronic pain

The theme of this year’s National Pain Week (22–28 July 2024) is ‘Pain colours your world’ – designed to highlight that for the 3.6 million Australians living with chronic pain, the impacts extend far beyond feeling pain itself.

The effects are also not limited to the person experiencing pain, with the reverberations extending throughout the economy and society.

Almost half of the respondents to the 2024 National Pain Survey have stopped working because of their pain condition, with around 30% needing to limit their hours.

Most (two thirds) feel that their condition strains their family relationships – whether through a lack of intimacy or inability to pick up their child.

With chronic pain taking an average of 3 years to diagnose, these findings illuminate the prevalence of underservicing and lack of support in the chronic pain space, said Nicolette Ellis MPS, Chair of Chronic Pain Australia.

‘Chronic pain is taking far too long to diagnose, and multidisciplinary pain management, which offers the best hope for controlling this complex condition, remains largely inaccessible,’ she said.

As the most accessed health professional by patients with chronic pain –  with 35% of respondents visiting a pharmacy once a month and 43% even more frequently – Australian Pharmacist delves into how pharmacists can help to improve the pain experience for these patients.

Medicine management missing in chronic pain care

When respondents were asked if they had been offered a medicine management plan, such as a Home Medicines Review (HMR) or MedsCheck, the findings revealed a  surprising lack of oversight, including:

• 40% have had their medicines reviewed by their GP 
• 18% have had their medicines reviewed by a GP and a pharmacist
• 3% had a review of their medicines solely by the pharmacist.

Many patients don’t know that HMRs are a freely available service, said Ms Ellis.

‘There’s a lack of understanding of what chronic pain is among healthcare professionals, which likely contributes to why patients don’t access medicine review services,’ she said.

With pharmacists’ wealth of knowledge in medicine safety, medicine reviews can be a great resource for re-challenging therapies, or looking at whether therapies are effective for a patient’s type of chronic pain – particularly when addressing functionality rather than solely focussing on reducing the pain experience.

Wendy Free, a female patient who has had multiple pain conditions – including cervical radiculopathy, trapped nerves, degenerative discs, and bursitis of the shoulder – said pharmacists’ medicine expertise has had a considerable impact on her pain management.

‘I would often go to my local pharmacy and speak with a pharmacist about medications I was prescribed,’ she said.

‘And the pharmacist took me aside and explained the risk of taking two medicines – fentanyl patches and gabapentin – together, how they could interact, and printed me out some information about what to look out for.’

‘Pharmacists can impart a lot of knowledge on goal setting – whether functionality, sleep or weight management – and tying that in with their medication management plan,’ Ms Ellis added. 

Better promotion of medicine reviews needed

With community pharmacists being the most accessed healthcare professional for patients with chronic pain, they have a ‘huge role’ in checking in with patients and improving access to medicine reviews.

‘They might have a credentialed pharmacist on staff, or a pharmacist who they refer HMRs out to,’ said Ms Ellis.

Broaching the topic with patients can help to ensure they remain the navigators of their own healthcare.

‘Community pharmacists reviewing a patient could say, “there’s a medicine review service available that you could benefit from”,’ she said. ‘If they’re informed about these services and know the value of them, they will likely drive that conversation with their GP as well.’

Younger patients with chronic pain need recognition

Chronic pain is often thought of as a condition that affects older people. However one in five Australians live with chronic pain – including children. 

‘Not only are they experiencing stigma, discrimination and barriers to care, but their mental health and self harm levels were very high compared to the rest of the population,’ she said.

If pharmacists raise awareness among younger patients that HMRs are available to help manage their chronic pain condition, it could help to build a rapport.

‘If we can promote the use of HMRs in younger populations and not just think of it as a polypharmacy service for older patients, it could demonstrate that there are health professionals out there who listen to them and appreciate they are living in pain,’ she said.

Patients need more control over their medicines

In the last three consecutive National Pain Surveys, similar findings have been unearthed about the prevalence of enforced opioid tapering – experienced by one in five respondents in this year’s report.

‘Our code is do no harm, but when we’re forcing people to do something they haven’t consented to, that actually causes more harm,’ said Ms Ellis.

In fact, patients are three times more likely to experience opioid toxicity or overdose when forced to taper from their medicines, she warned.

‘The research points to the fact that if patients are not consenting to tapering, it would be safer for them to stay on the current dose and initiate the conversation again in the future, or work with them on other strategies for their pain management.’

The ‘enormous amount of opioids’ that have become unavailable over the last year – either due to shortages or discontinuations – has also left people in the chronic pain community distressed about what’s going to happen in their care. 

When initiating the idea about opioid tapering or rotation with patients living with chronic pain, Ms Ellis advises to always begin with the patient identifying what’s important to them.

Once a good understanding of the patients’ pain condition, goals and how pain impacts their day-to-day life is established, pharmacists can start talking about what medicines are effective for their pain condition. 

‘If I’m looking at opioids, and I don’t believe that they’re currently very effective for their pain condition, and they’ve been on the medication for a long time, I’ll give them some other options,’ she said.

If tapering is the agreed upon approach, that doesn’t mean patients need to reduce down to zero.

‘In those consultations, patients will make the decision, indicate if it’s right for them, or there might be other options they’d prefer to try first,’ she said. 

‘It might be that we retest less than 10 mg of oral morphine equivalent in a reduction, or we might look at changing the agent altogether by rotating from one opioid to another.

After being referred for a medicine review, Ms Free’s medicines were optimised for both safety and efficacy, including a rotation of fentanyl to buprenorphine patches.

While this resulted in Ms Free experiencing blistering at the site of the patch, her pharmacist was able to relay this information to her GP and suggest a different treatment approach.

‘[The pharmacist] contacted my GP and informed her of an equivalent tablet that could help me in the same way and how much to take,’ she said.

‘Because pharmacists’ job is medications, they are a lot more informed about different medicines.’

Learn about the holistic management of pain and the efficacy of complementary medicines at the PSA24 session Pain busting supplements – what is the evidence base? on Friday 2 August from 3.30– 4.30 pm.