Alex Baker
Every day, community pharmacy teams are approached by patients seeking advice about over-the-counter (OTC) management of minor ailments[1],[2], and are able to ameliorate the risks associated with self-care of patients seeking specific OTC treatments[3].
Pain is the most common symptom that causes patients to seek the help of a healthcare professional[4]. Osteoarthritis (OA) is the most common cause of mechanical or activity-related joint pain, which is often accompanied by varying degrees of functional limitation and reduced quality of life. OA is one of the leading causes of pain and disability worldwide. The knees, hips and small joints in the hand are most commonly affected[5]. Many patients with joint pain will present to a community pharmacy seeking advice or to obtain pain medication from a member of the pharmacy team[6]. Much of the therapy for joint pain can be managed in a community pharmacy setting once serious causes requiring referral have been ruled out[7].
Importance of effective joint pain management consultations
The ability of all staff to correctly identify and manage patients presenting with mechanical joint pain is dependent on individuals being able to illicit the right information from the patient about their symptoms, without necessarily having access to the patient’s medical record. A two-way exchange of information between pharmacy staff and the patient is required to facilitate an effective joint pain management consultation
[3].
Engaging patients in a conversation about their symptoms can be challenging, especially if a specific medicine has been requested by the patient[8]. However, it is important to ellicit enough of the right information in order to aid therapeutic reasoning, guide appropriate decision making and deliver individualised patient care.
The ability to undertake the conversation is in itself not role specific, but more dependent on possessing the required consultation skills and the ability to understand the information obtained. Standardised education, training and care protocols are therefore required in order for all pharmacy team members to be able to conduct effective joint pain management consultations in a timely and consistently effective manner.
Standard operating procedures
Each pharmacy should have a standard operating procedure (SOP) covering the sale of medicines by various members of the pharmacy team. Team members include the pharmacist, preregistration trainee pharmacist, pharmacy technicians, dispensing assistants and counter-based colleagues. This will highlight the questions to be asked before a sale is made and the situations that require referral to the pharmacist or other relevant healthcare professionals.
The SOP ensures that members of the team work safely within their competence while also sharing best practice. It also maps the scope of practice for each team member that helps the responsible pharmacist identify knowledge limits, which is especially useful when supervising the sale of medicines on the premises.
Classifying joint pain
With enough information, community pharmacy teams should be able to distinguish between possible inflammatory arthritides (requiring urgent referral), and common mechanical or activity-related joint pain issues — the majority of which are manageable in a community pharmacy setting without the need for a radiological diagnosis[9].
Information gathering
Asking a series of questions, in addition to enquiring about the patient’s age, medications and allergies, is designed to facilitate the gathering of information related to joint pain symptoms and to help pharmacy team members correctly identify and classify the type of joint pain being experienced by the patient.
All members of the pharmacy team should be able to conduct an effective consultation with a patient presenting with joint pain using the questions in Box 1. If non-pharmacist members identify any ‘red flag’ symptoms from the answers supplied, or if the patient is taking any other medications or has any medical conditions or known allergies, prompt referral to a pharmacist should be made.
Box 1: Questions to ask in patient consultations on joint pain
These questions possess elements of both the WWHAM and SOCRATES tools traditionally used to facilitate information gathering in a community pharmacy setting (see Box 2).
When throughout the day do you experience joint pain and for how long?
Joint pain or stiffness experienced first thing after rising in the morning and lasting until the joints feel less stiff or ‘free up’ (generally less than 30 minutes in duration) is indicative of mechanical joint pain or osteoarthritis. Anything lasting longer than this requires GP review for possible referral to a rheumatologist as the cause may be inflammatory
[9].
No morning stiffness also means the severity of symptoms is maintained at the same level throughout the day.
How quickly has your joint pain or stiffness developed over time?
Gradual worsening of symptoms over a period of months does not warrant referral to the patient’s GP. However, rapidly worsening joint pain over days or weeks could be indicative of an underlying serious condition and requires medical review.
Do you have hot, swollen joints?
Presence of hot, swollen joints indicates inflammation and requires GP referral[9].
Have you experienced any fever or unexplained weight loss?
Any systemic upset experienced by the patient alongside their joint pain or stiffness is a red flag and should raise suspicion of something potentially more sinister. The patient should be referred for medical review[9].
Have you experienced any recent injury or trauma?
Pain and stiffness which does not happen immediately after trauma but that comes on hours or a day or so after trauma (e.g. sport or minor injury) can usually be managed with simple analgesia first rather than be referred for immediate medical review.
History of immediate pain following trauma warrants immediate medical review, typically at A&E. Similarly, persistent pain from an old trauma not responding to simple analgesia should be referred to the GP for clinical review.
Do you have any other medical conditions?
Patients previously diagnosed with cancer who are experiencing joint pain or stiffness should be referred promptly.
Red flag symptoms
The following symptoms are a cause for concern and require medical referral[7],[8]:
- A joint or limb that looks deformed with associated pain;
- A joint that is too painful to move or cannot bear weight;
- Severe swelling, discolouration, hot to the touch or bleeding;
- Persistent joint pain, tenderness or swelling;
- Prolonged or severe morning stiffness (more than 30 minutes duration);
- Feeling unwell or presence of fever;
- Tingling or numbness;
- Sudden or severe pain;
- A suspected fracture, dislocation, rupture or another serious injury.
Barriers to conducting effective joint pain management consultations
Several barriers to conducting effective joint pain management consultations have been identified in community pharmacy settings. These barriers appear to be associated with a lack of pharmacy knowledge or confidence in managing patients with joint pain, as well as limited consultation and/or communication skills. Physical barriers include lack of privacy, limited time, little to no remuneration, as well as the environment not appearing as a professional healthcare setting should.
Patient perceptions and past experiences also contribute to ineffective consultations, including lack of trust or confidence in pharmacy team members asking the questions, variations in practice between pharmacies and pharmacy team members, belief that they are capable of self-managing their own condition, being unaware that the consultation process is for their benefit, and little understanding of the risks associated with OTC treatments[3],[6],[10].
Addressing commonly identified barriers
Lack of knowledge and confidence
Training and upskilling of the whole team to facilitate delivery of best care within each team member’s competence is a quality marker in community pharmacy. Overcoming this particular barrier is essential in order to demonstrate pharmacy’s contribution and value in managing joint pain conditions — crucial when justifying the need for remuneration.
Pharmacists and pharmacy owners are responsible for the upskilling and training of the entire pharmacy team, ensuring responsibilities and allocated tasks are appropriate to the competence level and the best interests of the patient. Delivery of best-practice consultations and sharing the evidence that supports the agreed management plan is vital for confidence.
Privacy concerns
More than 90% of community pharmacies in England have a private consultation room[11]. Communicating to the patient that there is an opportunity to move the consultation into a setting that provides privacy and confidentiality is a priority as many people are unaware of this. It is also worth noting that many patients expect that consultations relating to joints will involve extensive physical manipulations and movements [12]; however, this may not always be the case, depending on which joints are affected. History is always the most important thing, both in terms of diagnosing the problem and in guiding whether any examination is required. As such, careful history taking should not be discarded.
Time pressures
Increasing dispensing workload and the expansion of community pharmacy services offered alongside the NHS self-care agenda means more people than ever will visit a pharmacy and require consultations with a pharmacist. Delegation of some tasks, upskilling non-pharmacist team members and ensuring the right skill mix in the team is the only way for the community pharmacist to be the clinician that the community needs. The need to redesign the workflow and review protocols and procedures should be seen as a regular exercise involving input from all team members and relevant colleagues. Appropriate use of technology also has a place in the design and delivery of person-centred care. Research proves that an effective consultation style is time efficient and delivers better patient outcomes[13].
Staffing pressures
Appropriate staffing levels in a community pharmacy are essential for the safety of patients and for the team to work effectively. The ambition of the pharmacy to be the first choice for patients must also take into consideration any factors that influence patient choice. Inadequate staffing levels are not only unsafe and detrimental to team morale, but also limit the ambition of the pharmacy to pursue new income streams and provide the highest quality care. Inadequate staffing may actually mask the presence of outdated work processes that no longer reflect current practice needs and the skill imbalance present in the team.
Box 2: WWHAM and SOCRATES
WWHAM
Historically, the use of acronyms, such as WWHAM, has helped to gather initial information at the pharmacy counter, especially with transactional queries[14].
W — Who is the patient?
W — What are the symptoms?
H — How long have the symptoms been present?
A — Action taken so far?
M — Medicines taken for anything else?
SOCRATES
The SOCRATES mnemonic is used by healthcare professionals to evaluate the nature of pain symptoms[15].
Site – Where exactly is the pain? What body part/joint is involved?
Onset – When did the pain start? Was it constant or intermittent? Gradual or sudden? Is it progressive or regressive?
Character – What is the pain like? An ache? Stabbing? Sharp? Burning? Tight?
Radiation – Does the pain radiate or move elsewhere?
Associations – Are there any other signs or symptoms associated with the pain (e.g. sweating, vomiting, temperature)?
Time course – Does the pain follow any pattern? Is it constant or does it happen at a specific time of the day? How long does it last? When did he/she feel the most pain?
Exacerbating/relieving factors – Does anything change the pain? What makes the pain better or worse? Sometimes, a specific physical position or medication can relieve the pain.
Severity – How bad is the pain? The patient should be asked to give a number to describe the pain on a scale of 0–10, where 0 is the lowest and 10 is the most severe pain experienced.
Citation:
The Pharmaceutical Journal, February 2019, online. DOI: 10.1211/PJ.2019.20205870
References
[1] Blenkinsopp A, Paxton P & Blenkinsopp J. Symptoms in the pharmacy: a guide to the management of common illness. Sixth edn. Oxford: Blackwell Publishing Ltd. 2009.
[2] Collins JC, Schneider CR, Faraj R et al. Management of common ailments requiring referral in the pharmacy: A mystery shopping intervention study. Int J Clin Pharm 2017;39:697–703. doi: 10.1007/s11096-017-0505-8
[3] Seubert LJ, Whitelaw K, Hattingh L et al. Development of a theory-based intervention to enhance information exchange during over-the-counter consultations in community pharmacy. Pharmacy 2018;6(4):117. doi: 10.3390/pharmacy6040117
[4] Gureje O, Von Korpff M, Simon GE et al. Persistent pain and well-being: A World Health Organisation Study in Primary Care. JAMA 1998;280:147–151. doi: 10.1001/jama.280.2.147
[5] National Institute for Health and Care Excellence. Osteoarthritis: care and management. NICE clinical guideline [CG177]. 2014. Available at: https://www.nice.org.uk/guidance/cg177 (accessed February 2019)
[6] Robinson J. Experts to develop referral pathway to aid joint pain management in community pharmacy. Pharm J 2019. doi: 10.1211/PJ.2018.20205666
[7] Conaghan PG. Pharmacy can do more for patients with joint pain, regardless of diagnosis. Pharm J 2019. doi: 10.1211/PJ.2018.20205664
[8] Watson M, Bond C, Grimshaw J & Johnston M. Factors predicting the guideline compliant supply (or non-supply) of non-prescription medicines in the community pharmacy setting. Qual Saf Health Care 2006;15:53–57. doi: 10.1136/qshc.2005.014720
[9] Cottrell E, Stanford C, Quicke J et al. Appropriate community pharmacy management and referral of patients with chronic peripheral joint pain. Pharm J 2019. doi: 10.1211/PJ.2018.20205710
[10] Suebert LJ, Whitelaw K, Boeni F et al. Barriers and facilitators for information exchange during over-the-counter consultations in community pharmacy: A focus group study. Pharmacy 2017;5:65. doi: 10.3390/pharmacy5040065
[11] Pharmaceutical Services Negotiating Committee. Essential facts, stats and quotes relating to pharmacy and pharmacy professionals. Available at: https://psnc.org.uk/services-commissioning/essential-facts-stats-and-quotes-relating-to-pharmacy-and-pharmacy-professionals/ (accessed February 2019)
[12] Versus Arthritis. Examination for musculoskeletal pain. Available at: https://www.versusarthritis.org/about-arthritis/healthcare-professionals/clinical-assessment-of-the-musculoskeletal-system/rems-general-principles/performing-a-regional-examination-of-the-musculoskeletal-system (accessed February 2019)
[13] Weiss MC, Platt, J, Riley R et al. Solicitations in GP, nurse and pharmacist prescriber consultations: an observational study. Family Practice 2013;30(6):712–718. doi: 10.1093/fampra/cmt042
[14] Rutter P. Community Pharmacy: symptoms, diagnosis and treatment; fourth edn. London: Churchill Livingstone; 2017.
[15] Macleod J, Munro JF & Edwards CRW. SOCRATES; 14th edn. Edinburgh: Churchill Livingstone; 2017.
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