What is PAIN?
• Pain is exactly what the patient says it is!
• Feeling triggered in the nervous system
• Sharp or dull
• Come and go, or it may be constant
• Feel pain in one area of the body – back, head, stomach etc.
• Feel pain all over, such as when your muscles ache from the flu.
• Way of body protecting itself – prevent serious injury by forcing patient to stop or alert patient to presence of underlying medical
• Acute Pain – goes away after treatment
• Chronic pain- can last for weeks, months even years
Pain is a natural part of life, affecting us all at different times throughout or lives. It can be recurrent pain that we experience regularly and are familiar with (such as back pain and joint pain). It can be pain that is caused by injury (sports injury or a fall). It can be pain with no obvious cause or it can pain resulting from a medical intervention such as surgery or side-effects of medication. Community pharmacies are most often the first destination for pain relief. Pharmacists and friendly trained pharmacy colleagues take the time to engage with patients one -on-one to offer some practical tips and recommend suitable products to meet their needs. A simple WWHAM interview is the starting point for all clinical consultations in the pharmacy.
A concise yet conversational WWHAM interview will allow the pharmacy colleague to recommend an appropriate product. The WWHAM interview will also capture information about symptoms that may be of concern. Such symptoms may require referral to the patient’s doctor or in more serious cases, the local emergency department.
When pharmacy colleagues should refer to the pharmacist before recommending a product:
•Request for a codeine containing OTC medicine
• Patient taking other medicines
• Recurrent headache
• Tried another OTC medicine, no improvement
• a baby or young child
• Suspected misuse of product
• Patient is pregnant
• Patient is breastfeeding
• Eye pain
• Ear pain
• Dental pain
• Elderly
• Severe debilitating pain
• Pain after trauma or head injury
• Pain post hospitalisation or surgery
• Pain associated with other acute symptoms
What are the most common types of pain that people present to the pharmacy with?
• Headache (tension, sinus, migraine)
• Muscle pain
• Joint pain
• Back pain
• Dental pain
• Sports injuries
• Ear pain
• Soft tissue injuries (bruises, strains, tendonitis, bursitis, sprains)
The three OTC oral analgesics
There are three oral analgesics available over the counter. They are available in products as the sole active ingredient or in combination with other active ingredients.
Aspirin
• Analgesic
• Antipyretic (reduces a fever)
• Anti-inflammatory
• Contra-indicated in under 16s
• Refer to pharmacist for patients on anticoagulants (blood thinners)
• Refer to pharmacist for patients with a history of gastrointestinal symptoms
Paracetamol
• Analgesic
• Antipyretic
• First line agent for pain and fever in children over 2 months
• Not an anti-inflammatory
• Caution not to take other products that contain paracetamol. Always read the label!
• Licensed for use in pregnancy when required
Ibuprofen
• Analgesic
• Antipyretic
• Anti-inflammatory. Ibuprofen is a Non Steroidal Anti-Inflammatory Drug (NSAID).
• Anti-inflammatory effect may take more than one dose but analgesic effect is immediate
• For children from 3months
• Variance between licensed OTC dose and prescription doses
• Caution not to take with other NSAIDs
• Refer to pharmacist for patients on anticoagulants (blood thinners)
• Refer to pharmacist for patients with a history of gastrointestinal symptoms
Some other ingredients seen in combination analgesic products
Caffeine
• Stimulant – lifts mood, increases alertness
• May increase the rate of absorption of the analgesic
Buclizine
• Helps reduce nausea and vomiting
• Found in Migraleve® pink tablets
Diphenhydramine
• Drowsy antihistamine
• Useful where nighttime pain prevents sleep
• Found in Panadol Night®
Topical NSAIDs
Topical non-steroidal anti-inflammatories (NSAIDs) are creams, gels, rubs, solutions or sprays that contain a nonsteroidal anti-inflammatory agent and are designed to be applied directly to the skin overlying a painful joint or area of bone. OTC topical NSAIDs contain the active ingredient diclofenac or ibuprofen.
• Absorbed through the skin
• Painkilling, anti-inflammatory action
• Fewer side-effects than when taken by mouth
Ibuprofen: Nurofen 5% Gel
Diclofenac (available in 1% and 2%): Voltarol Emulgel®, Diclac®
Category trends and growth
Moving Annual Total (MAT) is a tool used to analyse and compare sales over a period of time. The MAT (sourced from IQVIA)for the OTC pain relief category in Ireland for March 2023 (March 2022 to February 2023) compared to the MAT for March 2022 (March 2021 to February 2022) reveals growth of a massive 36%! However, this figure is misleading as the period from March 2021 to February 2022 was a time when pharmacy footfall was much lower and people were far less active due to the COVID-19 pandemic and associated public health advice.
The current year to date (YTD) trends show far less growth. There is 2% growth in terms of value on overall pain OTC products. The growth as per active ingredients is as per the below table:
This level of growth however has been driven primarily by price inflation. Some other trends of note from the data suggests:
• Paracetamol unit sales have dropped post the peaks seen during the COVID-19 waves.
• Topical pain relief sales are showing steady growth (+ 4%)
• Out of stocks and are skewing figures, however it clear to see that generics market share is growing. Eg. Core Nurofen -22%/ Brupro +22%
• One thing that remains constant is the continued demise of Aspirin as an OTC pain relief medicine. Paracetamol and ibuprofen are the two pillars upon which the OTC pain market is built.
Innovations and emerging trends
Whilst there hasn’t been the introduction of a new molecule to the OTC pain market, in recent years there has been some innovation with formulations and combination products. Examples include:
• Nurofen Durance 200mg Medicated Plaster
• Nurofen Long Lasting 300mg prolonged-release tablets/ capsules
• Easolief Duo 500mg/150mg tablets (paracetamol/ibuprofen combination product)
Codeine-containing nonprescription medicines
It is essential that all colleagues working in the pharmacy are trained to comply with the PSI’s Guidance for Pharmacists on the safe Supply to Patients of NonPrescription Medicines containing Codeine. The superintendent and supervising pharmacist are responsible for ensuring that the pharmacy has a standard operating procedure (SOP) in place to ensure that the guidance is complied with. Key points from the guidance include:
•The supply of codeine medicines may only be made by or under the personal supervision of a pharmacist who would be in a position to determine the appropriateness of the request.
•Such medicines must not be available for self-selection and must not be visible to the public.
•Every time a codeine medicine is supplied, the pharmacist must be satisfied that in the exercise of his or her professional judgement, the supply of such a medicine is the most appropriate treatment available at the time and that such supply is in the best interest of the patient. It should also be taken into account that non-codeine containing medicinal products for the same indications should be considered as first-line treatments, e.g. ibuprofen, paracetamol or aspirin
•The pharmacist has an important role to discharge the correct management of pain. This includes providing appropriate advice or medication and recognising the need for referral for further medical investigation.
•Codeine medicines should only be taken when the pharmacist considers it necessary and for the shortest period considered necessary. Combination products with ibuprofen and paracetamol recommend that the duration of treatment should be for no longer than three days. Any requirement for more prolonged use should only be considered under medical supervision.
•Patients should be advised of the importance of adhering to the recommended dosage and duration of use. Patients should be informed that chronic use and consumption of quantities in excess of the recommended dose, or for a prolonged period of time, may lead to tolerance, psychological and physical dependence and may result in the development of symptoms such as restlessness and irritability upon cessation of this medicine.
•The risks associated with overdose and/or prolonged use should be addressed with the patient.
•For products which also contain paracetamol or ibuprofen, the patient should be informed that these medicines have the potential to be harmful in overdose quantities or if used for a prolonged period of time.
•If patients experience the need to use codeine medicines over a prolonged period of time (i.e. more than three days) for pain relief or relief of another symptom, the patient should be referred to a medical practitioner who would be able to review their symptoms and provide appropriate treatment under medical supervision.
•Patients should also be counselled in the course of each supply in respect of other potential adverse reactions or side effects, including nausea, constipation, dizziness and drowsiness (which may impair their ability to drive safely). They should also be counselled, as appropriate, regarding the contraindications for use, drug interactions, or existing medical conditions, which may preclude the use of these medicines. The need for safe storage of these medicines should also be addressed with patients.
