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As healthcare literacy increases, patients are taking more control over their treatment. Many are driven to be more informed and involved with their healthcare, blurring the divide between patients and professionals[1]
. It is important for these patients to know how community pharmacies can help them take action, ensuring access to the right care at the right time.
Recently, the Royal College of General Practitioners introduced ‘3 before GP’, a 3-question routine that patients can employ to help relieve ailments without seeing their GP
‘Can I seek advice/treatment via a pharmacist?’ features prominently[2]
and highlights a newfound emphasis on self-care. The Oxford English Dictionary defines self-care as the practice of taking action to preserve or improve one’s own health[3]
; for acute conditions, this can mean taking an over-the-counter (OTC) pain reliever for a sore throat or a sprained ankle[4]
[5]
.
Now more than ever, pharmacists have a unique opportunity to introduce patients to the ways that pharmacists can help them practise self-care. The recommendations that they provide on OTC pain medications can empower patients to take control of minor ailments and may even change their lives.
Pain relief makes up a large part of sales of OTC treatments available in the pharmacy, with £566.5 million spent on OTC pain relief over 2017–2018 in Great Britain alone[6]
In the coming years, that number is likely to grow, due in part to new measures by the NHS to curb prescribing for minor conditions associated with acute pain and infrequent migraine, amongst others. It has been estimated that this plan could save the NHS approximately £38.9 million annually[7]
.
Unfortunately, common misconceptions can hinder pharmacists’ abilities to provide effective, evidence-based recommendations for OTC pain relief.
TRUE OR FALSE?
Ibuprofen should always be taken with food or milk.
FALSE: There is no evidence to support the benefits of taking OTC nonsteroidal anti-inflammatory drugs (NSAIDs) with food[8]
[9]
. In fact, studies have shown that taking NSAIDs with food can slow the absorption of the drug, which may result in delayed pain relief[8-10]
.
Gastrointestinal (GI) adverse events (AEs) with NSAIDs like ibuprofen are generally dependent on the dose and duration of therapy[11]
[12]
. Serious GI AEs associated with NSAIDs are rare, predominantly resulting from high doses and long-term use for chronic disorders. In a Cochrane review on acute postoperative pain in adults, the relative risks of experiencing at least one AE with a single dose of ibuprofen or paracetamol were not significantly higher than with placebo
[13]
. Furthermore, in a meta-analysis of repeated OTC doses of analgesics for mild-to-moderate pain, there was a 19% reduction in the relative risk of experiencing any AE with multiple doses of ibuprofen versus placebo over several days*[14]
.
Fast-acting formulations of ibuprofen wear off more quickly, requiring more medication to be taken over the long term.
FALSE: In a 2014 analysis, the number of patients needing remedication was signiï¬cantly lower with fast-acting ibuprofen compared with standard formulations[15]
. This is supported by a Cochrane review showing that better efficacy (low number needed to treat) tended to be associated with longer time to remedication[16]
.
All patients with asthma need to avoid NSAIDs.
FALSE: In patients with chronic asthma, the proportion of people who have NSAID-sensitive asthma is as low as 9%[17]
. This equates to about 1% of adults in the general population[17]
[18]
[19]
.
All NSAIDs significantly raise the risk of heart attack.
FALSE: Epidemiological studies do not suggest that low-dose ibuprofen (e.g. ≤1200 mg/day) is associated with an increased risk of arterial thrombotic events[20]
.
What’s slowing us down?
Further barriers to evidence-based recommendations for OTC pain management include restrictions by guideline developers to limit treatment options to one or two drugs. In this scenario, similar drugs are considered to operate as a class (NSAIDs, for example), and so only one is selected as the first or only option despite potentially important differences in pharmacokinetics or drug interactions. Less restrictive guidance, centred on patient-clinician interaction and evidence, may provide a better frame of reference[21]
.
How do we make the most of self-care?
The community pharmacist plays an important role as a healthcare professional in supporting self-care. While pharmacists know that they should follow the WWHAM** mnemonic, in some scenarios there is little evidence to show that pharmacists check patient information more often than assistants[22]
. In these situations, the opportunity to provide effective recommendations may be missed[22]
. However, research has shown that when staff do check with patients as to why they require pain relief and challenge their request, patients are usually led to buy the recommended product
[22].
How common is it?
A massive 80% of all care in the UK is self-care. Patients feel comfortable managing minor ailments when they feel confident in recognising their symptoms and can successfully treat their ailments using OTC medications[23]
. As a result, it was estimated in 2017 that online pharmacy will triple by 2024[24]
.
DID YOU KNOW[25]
:
- 1 in 20 Google searches is health related
- 60% of people take an OTC product before making an appointment with a doctor
- 59% of people take OTC products to manage acute health conditions
- 95% of people agree that self-care is strongly connected to taking personal responsibility for one’s health.
Recently, an experiential event broke new ground on exploring ways to disseminate information throughout the pharmacy and wider community
The Pharmacy Xchangeathon, created by RB, aimed to encourage pharmacists to better serve their communities by identifying common misconceptions regarding treatment recommendations for minor ailments. Presentations by key pharmacy specialists and a leading patient advocate served to highlight the current OTC treatment landscape using data and anecdotal evidence.
Brainstorming sessions during the event analysed knowledge and beliefs surrounding common OTC pain medications, with participants discussing ways to convey the idea of ‘the right painkiller for the right pain’ to pharmacy customers. To conduct the brainstorming sessions, teams were first arranged into three groups, with the goal of translating this idea into solutions for one of three categories:
- Knowledge — Ways to educate pharmacists and counter staff while challenging misconceptions
- Pharmacy — Methods for pharmacies to promote self-care and remain relevant in the changing retail landscape
- Community — Strategies for improving awareness of evidence-based data and promoting pharmacists as a resource for acute pain management.
Each of these teams was then divided in two, for a total of six teams who would pitch their idea to a panel of judges. There were three winning teams chosen, with the grand prize going to a pitch in the ‘Community’ category for an event called Kick Pain Week, promoting evidence-based recommendations for sports injuries. Kick Pain Week was chosen as the winning concept for its potential ability to connect directly with the community through sport. It was also noted that the implementation of this programme would be possible by many community pharmacies.
The importance of customer service was reiterated throughout the event. As many OTC medications are available to purchase online, guidance and customer service provided by the pharmacist and counter staff can mean a big difference to a pharmacy’s bottom line. What can you offer patients that the internet can’t?
Be a self-care leader
Pharmacists and their teams can position themselves as leaders of self-care in the community, when given the right tools. Keeping up to date on data for common OTC pain medications allows pharmacists to make evidence-based recommendations that are more likely to provide pain relief for minor ailments. The benefits of this are twofold: allowing pharmacists to be seen as leaders in pain relief and, in turn, helping patients feel more empowered to address pain directly.
How can you help create trust in your patients?
- Create a welcoming environment for your patients. If a patient needs to speak with a pharmacist, prioritise this over less immediate responsibilities
- Ensure your consultation room feels professional and clinical. Do not use this room for storage of retail items
- Understand what ‘normal’ is for your patient – are they looking to get back to skydiving, or do they just want to tie their shoes without pain?
*Ibuprofen is contraindicated in patients who have previously shown hypersensitivity reactions to aspirin or other NSAIDs
[20]. It is also contraindicated in patients with active GI bleeding or ulceration, a history of GI bleeding or perforation related to previous NSAID therapy and a history of recurrent GI haemmorhage[26]
.
**WHO is the patient? WHAT are the symptoms? HOW long has the patient had the symptoms? What ACTION has already been taken? Is the patient taking any other MEDICINES?
References
[1] NHS Clinical Commissioners. Five year forward view. 2014. Available at: https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf (Accessed January 2019)
[2] Royal College of General Practitioners. ‘3 before GP’: new RCGP mantra to help combat winter pressures in general practice. 2017. Available at: https://www.rcgp.org.uk/about-us/news/2017/december/3-before-gp-new-rcgp-mantra-to-help-combat-winter-pressures-in-general-practice.aspx (Accessed January 2019)
[3] Oxford English Dictionary. Self-care. 2018. Available at: https://en.oxforddictionaries.com/definition/self-care (Accessed January 2019)
[4] Self Care Forum fact sheet no. 10 (version 1.0.1.). Sore throat. 2013. Available at: http://www.selfcareforum.org/wp-content/uploads/2013/04/10-Sore-Throat.pdf (Accessed January 2019)
[5] Self Care Forum fact sheet no. 9 (version 1.0.1.). Sprains and strains. 2013. Available at: http://www.selfcareforum.org/wp-content/uploads/2013/04/9-Sprains-and-strains.pdf (Accessed January 2019)
[6] Statista. Sales value of over-the-counter (OTC) medicines in Great Britain from 2017 to 2018, by medicine category (in millions GBP). 2018. Available at: https://www.statista.com/statistics/415963/over-the-counter-otc-medicine-breakdown-of-sales-in-great-britain/ (Accessed January 2019)
[7] NHS Clinical Commissioners. Quick reference guide for healthcare professionals: conditions for which over the counter items should not routinely be prescribed in primary care. 2018. Available at: https://www.england.nhs.uk/wp-content/uploads/2018/05/over-the-counter-quick-reference-guide.pdf (Accessed January 2019)
[8] Moore RA. Analgesic safety - myths, mysteries and misconceptions. Int J Clin Pract Suppl 2015;(182):24–7. doi: 10.1111/ijcp.12655
[9] Rainsford KD, Bjarnason I. NSAIDs: take with food or after fasting? J Pharm Pharmacol 2012;64(4):465–9. doi: 10.1111/j.2042-7158.2011.01406.x
[10] Bjarnason I. Gastrointestinal safety of NSAIDs and over-the-counter analgesics. Int J Clin Pract Suppl 2013;(178):37–42. doi: 10.1111/ijcp.12048
[11] Bjarnason I. Ibuprofen and gastrointestinal safety: a dose-duration-dependent phenomenon. J R Soc Med 2007;100 Suppl 48:11–14
[12] Lanza FL. Endoscopic studies of gastric and duodenal injury after the use of ibuprofen, aspirin, and other nonsteroidal anti-inflammatory agents. Am J Med 1984;77(1A):19–24. doi: 10.1016/S0002-9343(84)80014-5
[13] Moore RA, Derry S, Aldington D, Wiffen PJ. Adverse events associated with single dose oral analgesics for acute postoperative pain in adults - an overview of Cochrane reviews. Cochrane Database Syst Rev 2015;(10):CD011407. doi: 10.1002/14651858.CD011407.pub2
[14] Lantéri-Minet M, Cucherat M, Benkhelil A. Sécurité d’emploi de l’ibuprofène en prescription médicale facultative chez l’adulte: méta-analyse comparative ibuprofène versus placebo et paracetamol. Douleur Analg 2015;28(2):100–15. doi: 10.1007/s11724-015-0420-5
[15] Moore RA, Derry S, Straube S, Ireson-Paine J, Wiffen PJ. Faster, higher, stronger? Evidence for formulation and efficacy for ibuprofen in acute pain. Pain 2014;155(1):14–21. doi: 10.1016/j.pain.2013.08.013
[16] Moore RA, Derry S, Aldington D, Wiffen PJ. Single dose oral analgesics for acute postoperative pain in adults - an overview of Cochrane reviews. Cochrane Database Syst Rev 2015;(9):CD008659. doi: 10.1002/14651858.CD008659.pub3
[17] Morales DR, Guthrie B, Lipworth BJ, Jackson C, Donnan PT, Santiago VH. NSAID-exacerbated respiratory disease: a meta-analysis evaluating prevalence, mean provocative dose of aspirin and increased asthma morbidity. Allergy 2015;70(7):828–35. doi: 10.1111/all.12629
[18] Simpson CR, Sheikh A. Trends in the epidemiology of asthma in England: a national study of 333,294 patients. J R Soc Med 2010;103(3):98–106. doi: 10.1258/jrsm.2009.090348
[19] Jenkins C, Costello J, Hodge L. Systematic review of prevalence of aspirin induced asthma and its implications for clinical practice. BMJ 2004;328(7437):434. doi: 10.1136/bmj.328.7437.434
[20] Nurofen 200 mg capsules. EMA SmPC. 2018. Available from: https://www.medicines.org.uk/emc/product/5936/smpc (Accessed January 2019)
[21] Moore A, Derry S, Eccleston C, Kalso E. Expect analgesic failure; pursue analgesic success. BMJ 2013;346:f2690. doi: 10.1136/bmj.f2690
[22] Nurofen: check, challenge & change mystery shopping stage. 2018. (Data on file)
[23] Self Care Forum. What do we mean by self care and why is it good for people? 2018. Available at: http://www.selfcareforum.org/about-us/what-do-we-mean-by-self-care-and-why-is-good-for-people/ (Accessed January 2019)
[24] Planet Retail. ePharmacies – a global strategic business report, OECD. 2018. (Data on file)
[25] IQVIA. Get ahead of consumer health trends across the globe. 2018. (Data on file)
[26] National Institute for Health and Care Excellence (NICE). Ibuprofen. 2019. Available from: https://bnf.nice.org.uk/drug/ibuprofen.html (Accessed January 2019)
UK/N/0418/0016h Date of preparation: January 2019.
This article has been sponsored, briefed and reviewed by RB.
