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Debbie
Paton: concordant approach |
People in chronic pain are often viewed as heartsink patients, but not
by Debbie Paton, who describes herself as “passionate about pain”.
“Chronic pain represents a hugely neglected patient population,” explains
Miss Paton, practice pharmacist, West Fife locality, Dunfermline and
West Fife Community Health Partnership. “Pain does not appear in
the general medical services contract so is often overlooked. It provides
a massive opportunity for pharmacists,” she says. And it is this
opportunity which Miss Paton is targeting through a primary care-based
pain management programme that she runs in partnership with a physiotherapist.
The aims of the programme are to promote self-management of chronic pain,
to optimise pain control medication while minimising adverse effects,
and to increase patient activity levels through
exercise.
Successful pilot
The service was born out of frustration. “It was initially driven
by community physiotherapists being held up with constant
rereferrals for patients with chronic pain,” says Miss Paton. This
led to the establishment of a pilot service involving both physiotherapy
and medication review. The pilot was a success and won a 2004 Pharmaceutical
Care Award (PJ, 2 July 2005, p14 PDF (730K)).
“At that stage, the service took a one-to-one approach. This meant
it was labour-intensive. However, it was clear that patients liked having
a better understanding of pain and of their medicines,” she says.
Another problem was that Miss Paton had to refer medication issues to
the patient’s
GP, something she tackled by becoming a supplementary prescriber in June
2005. Shortly afterwards, a newly designed service gained recurrent funding
from the CHP. This funding enables Miss Paton to devote two days a week
to the programme, spending the rest of her time as a practice pharmacist.
The new service is more structured than the pilot. “We decided
to fix the programme length at eight weeks. Before it was more ad hoc.
But if you make it too long patients’ commitment won’t be
sustained,” she says. Five programmes are run each year, each consisting
of eight once-weekly sessions for groups of 10 to 12 patients.
Patients are referred by their GP or physiotherapist. “The patients
we get are those who have no overall solution to their pain, with conditions
like fibromyalgia and complex regional pain,” Miss Paton explains.
“In the first week, I give an educational slot explaining the different
types of pain and the types of pain-killers, including which to use and
when. My key message is ‘by mouth, by clock, by ladder’.
In other words, I encourage patients to use oral preparations, to use
medicines regularly, and to step treatments up and down,” she says.
Between the first and second week sessions, patients are asked to keep
a pain diary. It is divided into two-hour sections and patients are asked
to score their pain level, note down what they were doing and record
what medicine they took. In the second week, Miss Paton undertakes a
formal medication review with each patient for which the pain diary is
crucial. “Obviously I focus on the analgesics but it is a full
review. If I identify problems with any other medicine then I make recommendations
to the GP,” she says. But as a supplementary prescriber, she is
able to tackle problems with analgesics immediately. She has a generic
clinical management plan which allows her to prescribe non-opioid analgesics,
opioid analgesics, non-steroidal anti-inflammatory drugs and certain
drugs for neuropathic pain. In addition, her CMP includes proton pump
inhibitors and laxatives to deal with the side effects of the analgesics. “The
benefit of using a generic plan is that it gives me flexibility. But
the doctors can remove drugs for certain patients, for example, opioid
analgesics if abuse is a problem.”
Miss Paton informs the GP of any changes to patient’s medication
by fax. And, at the end of the programme, she provides a detailed discharge
letter to the surgery describing exactly what was tried, what worked
and what did not. “Supplementary prescribing has been crucial to
the programme’s development,” she comments.
What problems do patients have? “The most common problem is that
patients do not take regular standard analgesia,” she says. In
many cases, patients miss lower steps on the pain ladder so have a high-strength
analgesic which they only take when they are in severe pain, the rest
of the time making do with no medication because they want to avoid side
effects. “The biggest change I make is to re-introduce regular
paracetamol.” However, patients are often either sceptical of paracetamol’s
benefits or concerned by taking the full dose of eight tablets a day. “I
have to recognise these issues. I take a concordant approach and it is
always the patient’s decision. But I tell them that the eight-week
programme is an opportunity to find out what suits them,” she says.
The middle part of the programme comprises group activity and education,
run jointly by Miss Paton and her physiotherapist colleague. Activities
include exercise, sessions about relaxation, posture, driving and self-help
gadgets, plus input from Pain Association Scotland. Patients can also
have individual physiotherapy and pharmacy appointments before or after
the group work. “I usually re-assess people’s medicines at
the fourth week. Then at the seventh week is a formal pharmacy follow-up,” says
Miss Paton. This involves developing a “Next steps” plan
for each patient. The plan details what medicines a patient should take
if his or her pain gets consistently worse, and what medicines to take
if the pain gets consistently better.
The final session is held in a local leisure centre to encourage regular
activity. Practical advice is also provided, for example about employment
and benefits. “But patients never completely finish the programme:
they can always telephone us for advice after the eight weeks are over,” Miss
Paton adds. Positive future
Initial evaluation of the programme has been positive. Over 100 medication
recommendations have been made, resulting in 47 per cent of patients
reporting reduced pain severity. “The trouble with pain is it
is hard to quantify results. But quotes from patients like ‘I
thought I would never work again and now I’m back in employment’ and ‘You’ve
changed my life’ are what gives me the feel-good factor,” says
Miss Paton, who is starting an MSc in pain next month which will enable
her to start providing cognitive behavioural therapy.
The programme was recently renamed “Rivers”, which comes
from the programme’s aims: “Relieving pain as we Inspire
change, impart new Vision with Exercise, Relaxation and Self-management”.
Possible future developments include allowing referrals into the programme
by community pharmacists and replicating the service in other parts of
Fife. |
The
Pharmaceutical Journal