Chronic pain: opioids and beyond,

supporting a multimodal approach

EXPERT COMMENTARY
Joyce McSwan Gold Coast Primary Health Network, Persistent Pain Program Clinical
Coordinator. BPharm, MPS, Cert IV TAE
This commentary is based on the aggregate results of the first 379 pharmacists, who
submitted data for around 3800 patients.

Background
One in five Australians,[1] will suffer chronic pain in their lifetime and up to 80% of people
living with chronic pain are missing out on treatment that could improve their health and
quality of life.[2]
Chronic pain is Australias third most costly health problem,[3] and studies have shown that
people with chronic back problems were significantly more likely to be in poverty than those
with good health.[4] Back pain and osteoarthritis are common forms of chronic pain and rank
second only to cancer as a leading cause of disease burden in Australasia.[5]
The main aims of treating chronic pain are to provide an effective return to function and to
improve coping skills and quality of life.[1,6] Management should focus on using nonpharmacological strategies[7] and self-management.[1] While growing evidence supports a
multimodal approach involving a combination of non-pharmacological and pharmacological
management, a recent survey showed medicine alone to be the most common form of
management within primary care.[8]
Medicines are used in the management of chronic pain but there is limited evidence for the
long-term use of opioids (as opposed to use in acute pain, when opioids work well).[1] Thus
the role of opioids in a patients drug treatment should be reviewed regularly.
Effective pain management can reduce the suffering that chronic pain brings and requires a
multidimensional (multimodal) approach recognising that psychosocial, environmental and
biomedical factors contribute to the pain experience that is produced by the brain.[9] This
biopsychosocial approach manages the patient as a whole rather than pain as a symptom
only.[1]
A biopsychosocial approach to the management of chronic pain remains a new concept that
is currently poorly adopted into day-to-day practice. Factors challenging this collaborative
approach include:

a lack of health professional knowledge that pain is a chronic condition and no longer
considered just a symptom

patients beliefs about the role of medicines

poor understanding by health professionals and patients, of the risks of over-treating and
under-treating pain

inadequate consistency of health professional practice.

Pharmacy Practice Review

Chronic pain: opioids and beyond, supporting a multimodal approach

Results
It was pleasing to see that pain management goals other than pain reduction alone
were discussed with most patients (85%).
Such discussions commonly form part of patient education[7] and not only build trust and
rapport with the patient but also provide a very important platform for patients to explore the
different perspectives of pain and will empower them to remain active in their own self-care.
While the pharmacist will assist the patient to identify desired goals in pain management it is
also important that the goals are not those of the clinician, but the patients own identified
goals.
Discussing, and adjusting where needed, treatment expectations and ensuring that the
patient understands that it may not be possible to eliminate pain completely and fully restore
function is important.[10,11] This allows modalities that improve the patients functional goals,
quality of life, and ability to better cope despite pain, and the ability to meet other life goals, to
become a higher priority in their pain management plan. Having realistic and achievable
patient goals is very important.[7]

While 77% of patient interactions involved discussing how well the patients current
pain management was working, one would hope that, in line with the quality use of
medicines, pharmacists are routinely checking for effectiveness in the patients pain
management plan.[1]
Assessing the effectiveness of a patients current pain strategy is important, as it will allow the
pharmacist to identify any gaps in management and further navigate the patient towards
recovery early on. Patients who do not have an outcome-driven plan will simply not achieve
the pain reduction they desire, and those who are not achieving their function and pain
management goals or do not have goals other than pain reduction should be referred back to
their doctor.
Patients who require further multidisciplinary input should be referred to suitable local allied
health professionals who have expertise in managing chronic pain. Promote selfmanagement, at first with help from allied health providers, as this will provide a more
sustainable future for ongoing management. Interdisciplinary referrals and collaborations will
better equip the patient for recovery and equally expand the pharmacists own clinical
network. Pharmacists can, if confident, make these referrals, or alternatively make
recommendations or provide information for the patient to discuss with their doctor.

In most cases (83%) patients were asked if they were aware of a pain management plan
that had been developed for them.
All patients with chronic pain should have an individual management plan.[1] Pain is a
complex and dynamic process and for optimised management it requires a plan that is
suitable for the individuals needs and is able to be reassessed and reviewed regularly. A pain
management plan will also help highlight priority areas, focus attention towards the patients
goals and help to direct discussion with the view to assessing how well management is
working and how the pharmacist can best support it. Ask all patients with chronic pain if they
have a pain management plan and, if they do not, suggest they discuss developing a pain
management plan with their doctor.

Pharmacy Practice Review

Chronic pain: opioids and beyond, supporting a multimodal approach

While the benefits of a multimodal approach and value of non-pharmacological

strategies were discussed with 78% of patients this is best practice[1] and is vital, without
which the biopsychosocial model of pain management cannot be applied. Active nonpharmacological approaches should be recommended over passive non-pharmacological
approaches,[11] as they have the greater potential to readapt a sensitised neurological
system.[12] Active non-pharmacological approaches will also lower the patients reliance on
health professionals and the healthcare system, and promote greater self-care and
independence in their own pain management.

It is encouraging to see that assessments for potential drugdrug interactions were

completed for 87% of patients.
It is pleasing that the results showed that pharmacists were vigilant at monitoring risk through
these discussions with the patient. It is essential to monitor for drugdrug interactions;[1] this
is especially important for patients using combinations of medicines as part of their pain
management.

Potential adverse effects were discussed with 91% of patients and an assessment for
adverse effects was completed for 91% of patients.
It is well known that opioids carry a high risk of potential long-term adverse effects[13] as well
as short-term transient adverse effects that can be poorly tolerated. It is important to make the
patient aware of these risks, including the well-known risk of dependence[14] as well as the
risks associated with taking higher than recommended doses of prescription or nonprescription opioids.[1] Generally, high doses of any medication have increased risk of
adverse effects.

Both verbal and written information was provided to 73% of patients.

This finding should motivate pharmacists to think about how they can improve the
communication of information about new ways of managing chronic pain. For example, there
is a need to educate patients that medicines will only work in around one-third of patients and
modify the pain experience by about 30% to 50%.[1]
A conversation to explain clearly what can be realistically achieved is therefore often
required.[15] This knowledge allows the patient to transition from thinking about fixing or
curing chronic non-cancer pain to considering the physiological, emotional and psychological
responses that contribute to the pain experience and reducing contributors to those factors.[1]
Changing patient perceptions can be very difficult and challenging for those working at the
coal face encountering this on a daily basis. For a medicine-focused patient to consider
managing their pain in a different way can be daunting and worrying. Trust and rapport based
on the ongoing relationship he/she has with their pharmacist is critical for the opportunity of
change.
Communication is the key to effectively convey todays evidence in pain management to the
patient. Communication through different media is necessary to facilitate the patients
understanding, and both verbal and written forms of information dissemination is necessary.
It is important that pharmacists can efficiently locate credible resources relevant to the
patients needs and confidently guide their patients through change. Providing written

Pharmacy Practice Review

Chronic pain: opioids and beyond, supporting a multimodal approach

information will also provide the busy patient with something to take home to read, and this
type of communication may be less confronting, giving the patient the opportunity to consider
the information provided and return for further discussions.
The pharmacists role in understanding the science and empowering patients to embrace the
information can be optimised by having well-practised motivational interviewing skills. This is
a necessary core skill to have in the area of pain management.

Summary and recommendations

Pharmacists are positioned at the coal face of the community and have an important role to
play in the growing area of pain management. The following approaches can assist
pharmacists to identify needs and support patients experiencing chronic pain, and optimise
achievement of their treatment goals.

Review your understanding of chronic pain and its complex dimensions.

Review the patients goals and the effectiveness of their current treatment strategy in
achieving these, at each episode of care.
Educate patients on the lack of evidence to support long-term opioid use in chronic pain
management.
Educate patients on the multimodal approach offered, including the need for nonpharmacological strategies and self-management.
Reassure the patient that the synergistic combination of both pharmacological and nonpharmacological approaches will better manage the many factors that can impact their
pain experience.
Encourage the patient to have a written pain management plan that is regularly reviewed,
acknowledging that pain is a dynamic process and as the pain changes, the plan will also
change accordingly.

References
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Expert Group for Analgesics. Therapeutic Guidelines: Analgesic, version 6.

Melbourne: Therapeutic Guidelines Ltd, 2012.
National Pain Summit Initiative. National Pain Strategy. Victoria 2010.
Access Economics Pty Limited. The high price of pain: the economic impact of
persistent pain in Australia. Sydney: MBF Foundation in collaboration with University
of Sydney Pain Management Research Institute, 2007.
Schofield DJ, Callander EJ, Shrestha RN, et al. Labor force participation and the
influence of having back problems on income poverty in Australia. Spine (Phila Pa
1976) 2012;37:1156 - 63. http://www.ncbi.nlm.nih.gov/pubmed/22166931
Global, regional, and national incidence, prevalence, and years lived with disability
for 301 acute and chronic diseases and injuries in 188 countries, 1990 - 2013: a
systematic analysis for the Global Burden of Disease Study 2013. Lancet
2015;386:743 - 800. http://www.ncbi.nlm.nih.gov/pubmed/26063472
Rossi S, ed. Australian Medicines Handbook. Adelaide: Australian Medicines
Handbook, 2014.
New South Wales Health. Chronic pain management: Information for medical
practitioners, 2013.

Pharmacy Practice Review

Chronic pain: opioids and beyond, supporting a multimodal approach

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Henderson JV, Harrison CM, Britt HC, et al. Prevalence, causes, severity, impact, and
management of chronic pain in Australian general practice patients. Pain Med
2013;14:1346 - 61. http://www.ncbi.nlm.nih.gov/pubmed/23855874
BPAC. Helping patients cope with chronic non-malignant pain: it's not about opioids.
Best Practice Journal 2014:28 - 38
Cohen ML. Principles of prescribing for persistent non-cancer pain Australian
prescriber;36:113 - 15 http://www.australianprescriber.com/magazine/36/4/
article/1427.pdf
Zekry O. Chronic Pain Australian Pharmacist 2015:35. http://www.psa.org.au/
membership/australian-pharmacist
Holliday S, Hayes C, Dunlop A. Opioid use in chronic non-cancer pain Part 2
Prescribing issues and alternatives. Aust Fam Physician 2013;42:104 - 11
http://www.racgp.org.au/afp/2013/march/opioid-use-part-2/
McDonough M. Safe prescribing of opioids for persistent non-cancer pain Australian
prescriber 2012;35:20 - 4.
Nielsen S, Cameron J, S. P. Over The Counter Codeine Dependence. Victoria: Turning
Point Alcohol and Drug Centre, 2010.
Medicines Regulation and Quality. Quick clinical guideline for the use of opioids in
chronic non-malignant pain. https://www.health.qld.gov.au/persistentpain/docs/
ddu_quick_guide.pdf Queensland Government 2012

The commentary provided in this Pharmacy Practice Review has been provided by Joyce
McSwan and does not necessarily reflect the views of NPS MedicineWise.
Date published: March 2016

Not for citation or publication

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Pharmacy Practice Review

Chronic pain: opioids and beyond, supporting a multimodal approach