The pain category continues to have the greatest share of the OTC market. Community pharmacies are often the first port of call for patients experiencing mild to moderate pain. Pharmacists and their trained teams are experts at triaging pain and recommending appropriate action for patients.
It is essential that all pharmacy team members know the medicines in your pharmacy that contain paracetamol and are familiar with the dosage.
Using the WWHAM model, pharmacy colleagues can recommend appropriate products to alleviate pain or refer further if necessary. There are three main molecules that are most often requested for pain in pharmacy – paracetamol, ibuprofen, and codeine. It is important that the WWHAM technique is used appropriately as these are important drugs and effective counselling on side effects and usage is essential. They can also interact with many prescription medications so knowing what other medications the patient is taking is necessary too.
The main reasons patients visit community pharmacies for pain advice are:
• Migraine
• Tension Headache
• Back pain
• Muscle and joint pain
• Dental pain
• and Sports Injuries.
Paracetamol and Ibuprofen are still the main molecules in the category. Paracetamol is an analgesic and antipyretic.
Ibuprofen is an anti-pyretic, analgesic, and anti-inflammatory. It should not be used with other NSAIDs and can interact with medications and conditions. It is important to know if the patient has GI problems or is taking other medication e.g. blood thinners.
There are restrictions on the sales of these products that all pharmacy staff must know and follow.
It is essential that all pharmacy team members know the medicines in your pharmacy that contain paracetamol and are familiar with the dosage. Good counselling is essential for all pain products. It is important the patient is aware of the dosage and form e.g. cough cold flu remedies that customers may not realise contain paracetamol or that have a single dose with 1g paracetamol. Paediatric counselling of pain medication is essential and ensuring the correct dosage is known to the patient for the age of the child and the form e.g. suppositories.
Paracetamol containing products are the drugs most often used for self-harm and can also be associated with suicide. Approximately 500 people die by suicide every year in Ireland. There were almost 11,000 intentional paracetamol containing overdoses recorded between 2007 and 2018 by people under the age of twenty-five. More than one pack of paracetamol containing medication should not be sold to a customer at any one time. Exceptions to this include when the total combined dosage of multiple packs does not exceed 24 x 500mg units or the pharmacist is satisfied that it is safe following direct consultation with the customers. The HSE have a current campaign targeted at staff in pharmacy, to remind them of the restrictions on the sales of paracetamol-containing medications that they should always know and follow. It has been developed to promote the safe sales of paracetamol, from a self-harm and suicide prevention perspective – and to reduce the incidence of paracetamol related intentional drug overdose in Ireland. Supports such as posters and patient cards are available to order at https:// www.hse.ie/eng/services/ list/4/mental-health-services/ connecting-for-life/publications/ safe-sales-of-paracetamol.html If you are concerned about a customer who is trying to buy excessive amounts of paracetamol containing mediation always refer to the pharmacist. Pharmacists can refer patients to supports, many are available 24/7 and you can make contact in different ways, for example: on the phone – Samaritans – freephone 116 123, by text message – Text About It – text HELLO to 50808, online – MyMind, face-to-face – Pieta –freephone 1800 247 247. You can also call the HSE YourMentalHealth Information Line, anytime day or night, for information on mental health, and what other services and supports are available near you. Freephone 1800 111 888 or visit www.yourmentalhealth.ie.
Overall, the pain category has settled after the pandemic and is now in sustainable continued growth. Like all medications in Ireland, shortages have impacted the category this year. This has seen patients try alternative products to ones they were more familiar with and seen movement across products in the category. Products that have been around for a while are becoming more popular like Solpa Extra (paracetamol /caffeine), Panadol Extra (paracetamol/ caffeine) Excedrin (Aspirin/paracetamol/ caffeine) for migraine and dual molecule product Easolief Duo (paracetamol / ibuprofen).
Topical application products are seeing a lot of growth either as a rub or gel applied directly to the area of pain or a patch. Side effects particularly GI disturbances are reduced by this form of application. Voltarol Emugel Extra Strength 2% gel and Diclac Relief 1% gel that contain diclofenac as the active ingredient are the leaders. Patches have become more popular with patients and products like Nurofen Durance 200mg plaster, and Voltarol Heat patch are seeing growth.
Patients are looking for holistic solutions to there symptoms. Along with traditional pain relief molecules, customers are looking for complimentary products to alleviate pain. Heat patches are number one in this category with Deep Heat and Thermacare Patches the market leaders. VMS products containing turmeric or products like Revive Joint active are used by customers for inflammation and prevention of ongoing pain. Cool and Soothing patches can complement migraine pain relief. There are little to no requests for products like Tens machines that in the past were very popular with patients.
The category can be very price driven and patients are price sensitive. We are seeing growth in single molecule generics particularly. Branded products are growing with product extensions and offering targeted products that patients want. For example, those with dental pain are likely to request products like Nurofen rapid release maximum strength 400mg capsule or Nurofen long lasting prolonged release 300mg capsule.
We cannot review the OTC Pain category without discussing Codeine which has featured in media articles and TV programmes this year. Codeine is a mild to moderate opioid (narcotic) analgesic and has weak cough suppressant activity; when supplied as a nonprescription medicinal product for the relief of pain codeine is used in combination with other analgesics such as paracetamol or ibuprofen. It should only be supplied when the pharmacist deems a supply is necessary and only when a non-opioid analgesic, e.g., paracetamol, aspirin, or ibuprofen, has not effectively relieved the patient’s symptoms. Consumption of quantities more than the recommended dose, or consumption over a prolonged period, may cause tolerance and dependence and may result in withdrawal symptoms such as restlessness and irritability upon stopping the medicine. Regular or prolonged use of codeine containing products may produce psychological and physical dependence. For combination products, use of higher doses and/or for a longer duration than that recommended can also lead to serious adverse clinical outcomes arising from exposure to the analgesic component (e.g. paracetamol or ibuprofen). These include hepatotoxicity, gastrointestinal and renal toxicities, such as gastrointestinal haemorrhage and perforation and renal failure.
The PSI Non-Prescription Medicinal Products Containing Codeine: Guidance for Pharmacists on Safe Supply to Patients gives pharmacists information on necessary counselling for codeine products. Pharmacists should outline to the patient that the lowest effective dose for the shortest period should be used, with a maximum of 3 days use. When it is not appropriate to supply a codeine product. The pharmacist should discuss the reason the medication is not suitable with the patient and offer alternative treatments/ supports. If dependence is suspected the pharmacist on duty should engage with the patient and make all reasonable attempts to ensure that the patient is facilitated and encouraged in accessing services which will assist in the management of that dependence. The Irish pharmacy union have great supports for pharmacists and their teams on supplying codeine. They have a codeine checklist, patient information card, guidance on spotting signs of abuse or misuse and what to do if abuse is suspected.
Written by Emily Kelly, Community Pharmacist McCauley Pharmacy
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