Experts to develop referral pathway to aid joint pain management in community pharmacy

Pharmacy teams have a vital role to play in achieving best practice for patients with joint pain as part of the multidisciplinary team, but they require the right support and training to develop the confidence and knowledge to do so. This was the key message of a round-table event hosted by The Pharmaceutical Journal on 10 July 2018.

The round-table, which was hosted at the London offices of the Royal Pharmaceutical Society (RPS), was held to discuss how best to manage patients with joint pain in community pharmacy.

The experts invited to join the discussion, which was chaired by The Pharmaceutical Journal’s careers editor Angela Kam, included pharmacists, rheumatologists, general practitioners, physiotherapists and a dietitian representative from the charity Arthritis Action.

A survey of community pharmacists, conducted by the journal, looked specifically at current management of osteoarthritis (OA), including consulting patients with OA in community pharmacy. However, recent evidence has revealed variation in practice and a number of barriers for pharmacy teams when dealing with patients who experience joint pain in general. The survey results discussed below are related specifically to OA; however, as the panel discussed the results, it was made clear that many of the issues related to OA are relevant for joint pain in general. As a result, the panel has agreed to work together to develop a referral pathway to help guide and drive best practice in community pharmacy for managing all patients who present with joint pain, and not OA exclusively.

Barriers to pharmacy engagement in osteoarthritis

Around 8.75 million people in the UK receive treatment for OA — the most common site for pain being the knee, followed by the hips and then the hands and feet. Many of these individuals will present to community pharmacy at some point in their care, so it is important that the whole pharmacy team has the appropriate training and knowledge to deal with them.

Barriers identified by respondents included a lack of patient trust in pharmacists

The survey’s results highlighted that a number of barriers exist for pharmacists when conducting in-depth consultations with patients experiencing OA symptoms. The majority of respondents (77%; n=316) cited limited time as a barrier, while just under 40% (n=160) cited lack of staff, 34% (n=138) cited lack of knowledge and 28% (n=114) cited lack of confidence dealing with patients experiencing symptoms of OA. Just under 23% (n=94) stated that conducting an in-depth patient consultation was outside of their scope of practice.

Other barriers identified by respondents included a lack of patient trust in pharmacists and limited referral routes.

Of the 699 people who responded to the survey, 40–50% said they were exposed to between 1 and 5 patients per week presenting with joint pain, stiffness, muscle pain or back pain. Over 10% of respondents said that they managed more than 15 patients per week presenting with one of these types of pain.

Just under 50% of respondents (n=232) claimed that, on average, they spoke to adult patients presenting with OA about their symptoms more than once per week, but not daily. A fifth (20%; n=95) noted that they did this at least once per day.

But the panel highlighted that interactions with patients living with OA are not always carried out by pharmacists and that the whole pharmacy team should be considered when discussing training needs. “Counter assistants have the most contact with patients and may be the only person they speak with on that visit to the pharmacy,” said James Alman, a pharmacist at Hillside Pharmacy in Church Stretton.

“It’s time to challenge the traditional pharmacy [team] model,” added Thomas Richards, a professional support manager at Lloyds Pharmacy. “The people [that patients with OA] interact with first are the least qualified people — unless they are referred on.”

Most patients will present very late to their GP — most already come into the community pharmacy as part of their daily or weekly routine

Ade Williams, superintendent pharmacist at Bedminster Pharmacy, Bristol, has a special interest in musculoskeletal pain management. He said that the pharmacy team is evolving: “When you come into a community pharmacy, you are meeting highly regulated but also increasingly competent members of the pharmacy team — this is changing the way that community pharmacy works. The counter assistant [role], which used to just be a sales of medicines role, has now morphed into a healthy living advisory role. The pharmacist is no longer the sole person — we have the opportunity to change the way we address and deal with patients – we have to become a much more holistic team.”

In the majority of cases, respondents said that patients with OA symptoms generally self-presented for consultation at their pharmacy, for example when seeking advice about symptoms or treatment options, or when purchasing an over-the-counter (OTC) analgesic. Williams noted that this reflected what he saw in practice: “Most patients will present very late to their GP — most already come into the community pharmacy as part of their daily or weekly routine so it’s easier to see mobility and limitation impact on patients day to day.”

With this in mind, it was agreed that more needs to be done to ensure pharmacy teams have the resources to manage patients with OA effectively.

Understanding of osteoarthritis

The survey revealed that although the respondents had some knowledge of the signs and symptoms of OA, some improvement in understanding was required.

According to the National Institute for Health and Care Excellence (NICE), OA should be diagnosed clinically without radiological investigation if a person is at least 45 years old, has activity-related joint pain and has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes. Rapid worsening of symptoms or the presence of a hot swollen joint may indicate alternative or additional diagnoses.

Once you do explain OA in terms of chronic concepts, it’s actually a very positive condition

Around 78% of respondents (n=361) said the signs and symptoms of OA were activity-related joint pain or stiffness and 77% (n=354) said loss of flexibility. Just over 50% (n=233) said a grating sensation and 43% (n=196) said no morning joint stiffness, or morning joint stiffness lasting less than 30 minutes. Just under 4% (n=17) of respondents admitted that they did not know the signs and symptoms of OA.

Philip Conaghan, a rheumatologist and professor of musculoskeletal medicine at the University of Leeds, said that it would be useful if pharmacists had a simple algorithm to use according to the location of a patient’s joint pain. “Have you recently had a fall? Is your shoulder worse when you reach up or when you’re lying in bed? You can give very common scenarios for each region,” he said.

 Michael Doherty, professor of rheumatology at the University of Nottingham, said that it is important to get an idea of what a patient’s perceptions of OA are when they start to get regional pain, as they are often negative and may think there is not much you can do about it. “Once you do explain OA in terms of chronic concepts, it’s actually a very positive condition. Our skeletons have all got OA in them, and 90% or more of OA never causes any problems,” he said.

Doherty went on to explain that OA is a risk factor for regional pain and that the correlation between structural change and pain in many parts of the body is very poor. “OA is a very active, metabolically dynamic process affecting all tissues and joints … the risk factors for pain at presentation are very different to the risk factors for OA”, he said. By discussing this with patients, Doherty added, it is then easier to motivate them in strategies that can help.

The survey found that respondents had a limited knowledge of the risk factors associated with OA. More than 83% (n=379) said that obesity was a risk factor, 76% (n=348)  said being over 45 years old was a risk factor, and just over 67% (n=308) said joint overuse was a risk factor.

In terms of the common complications, the majority of respondents (63%; n=246) cited depression and 46% (n=179) said polypharmacy. Around a fifth also selected anxiety (27%; n=104), osteoporosis (25%; n=98), a pinched nerve (23%; n=90) and stress fractures (27%; n=106) as common complications. Under ‘other’, respondents said bunions, sleep disturbance, mobility problems and altered lifestyle were all complications associated with OA.

The prevalence of depression in OA patients is around 20% and around 31–41% of patients with OA experience anxiety

Martin Lau, a dietician representative from Arthritis Action, said that sleep disturbance is one of the issues many people with OA want to discuss. When partnered with reduction in movement, this can limit an individual’s ability to work, leading to both financial hardship and emotional stress. Additionally, the persistent pain being experienced by these individuals can lead to a higher risk of anxiety or depression.

“The prevalence of depression in OA patients is around 20% and around 31–41% of patients with OA experience anxiety,” Lau explained.

When asked how they would normally assess an adult OA patient’s joint pain and stiffness, 88% (n=373) said they would ask them how long they had been experiencing pain and stiffness, and just over 84% (n=355) said they would ask if and how they had already tried to treat the pain and stiffness. Almost 78% (n=331) of respondents said they would ask at what time of day they experienced pain and stiffness, and whether the pain and stiffness stopped them from carrying out their normal daily routine.

Around 7% (n=29) of respondents said they would not ask their patients to describe their pain and stiffness, and when choosing to give ‘other’ assessment techniques, respondents said they would consider symmetry of pain, SOCRATES (site, onset, character, radiation, associations, time course, exacerbating/relieving factors and severity), weather and temperature, and sleep interruption.

Managing osteoarthritic pain in community pharmacy

The second part of the survey asked respondents about the pharmacological and non-pharmacological management of OA. According to NICE, lifestyle interventions are at the core of OA treatment; in keeping with this, 80% (n=335) of respondents to the survey said they would recommend weight loss and just under 69% (n=289) said they would recommend a healthy diet. Despite not being recommended by NICE, 42% (n=175) said they would recommend supplements, such as glucosamine and chondroitin.

Around 62% (n=258) also said they would promote regular aerobic exercise to their patients to promote strengthening and range of movement, while 54% (n=227) said they would recommend physiotherapy. “Strengthening exercises are effective for people with OA,” said Johny Quicke, a National Institute for Health Research (NIHR) academic clinical lecturer in physiotherapy. 

“It’s also about finding what people enjoy — things they may already do on a day-to-day basis — and tailoring therapeutic exercise and lifestyle advice.”

Pharmacists can recommend several strengthening exercises to patients with joint pain

Quicke said that pharmacists can recommend several strengthening exercises to patients with joint pain. For example, for knee pain, sit-to-stand exercises, functional exercises, cycling, low-intensity aerobic exercise, swimming and walking. He noted that Versus Arthritis (formerly Arthritis Research UK) has produced a booklet called “Keep Moving”, which contains a range of exercises for different joints in the body, adding that pharmacists can easily signpost it or give it out in the pharmacy.

In terms of resources, Conaghan noted that it would be helpful if pharmacists could recommend three or four safe and reputable OA websites, as many patients will carry out online searches but end up looking at “useless” sites. Alastair Dickson, a GP, health economist and communications officer for Primary Care Rheumatology, added that the NHS Health Apps Library is a useful place to start, as all websites recommended are worthwhile and validated, and can be signposted to.

Lau noted that patients may speak to their pharmacist regarding dietary supplements and that pharmacists can use this as a springboard for recommending healthy eating. “If their body mass index is a little higher, [pharmacists] could initiate tactful conversation in terms of weight loss,” he added.

But signposting does not just have to be to online or paper resources, the experts concurred — signposting patients to local pools or parks within the community could also be helpful in promoting a healthier lifestyle.

“In Bristol we have walking groups,” explained Williams. “These people are vulnerable to becoming more isolated from the community, and fear of losing independence is a big factor [in OA].

“[Patients need] motivation to engage with all the little things that will help.”

However, Alman highlighted that, up until recently, pharmacists have not been very confident in the nonpharmacological management of OA. “[Pharmacists] need regular contact with patients … if there are no contraindications for a drug there is no reason not to supply it, but it’s important to be clear that the pain relief will not improve OA like physio or exercise,” he explained.

In terms of NICE-recommended OTC analgesics, 74% (n=305) of respondents to the survey said that oral paracetamol was recommended as a first-line treatment option for use in patients with OA. Around 49% (n=202)  said topical nonsteroidal anti-inflammatory drugs (NSAIDs) were recommended as the first-line treatment, while just over 40% (n=167) said oral NSAIDs were recommended. Just under 9% (n=35) of respondents said they did not know what the first-line treatment options were.

“The whole [pharmacy] team needs to be aware that painkillers don’t solve the problem — they help the body solve the problem. It gets over this idea that you need stronger and stronger painkillers,” said Dickson. “The biggest problem with patients is that they don’t want to take painkillers,” he added, saying that with patients in the over 65 years age group, if they are taking a painkiller of any kind, “they feel they’re broken”. Topical treatments, he added, are a “reasonable compromise”.

Patients prefer topical pain relief, agreed Doherty: “We haven’t got a good systemic analgesic that is effective, well tolerated and relatively safe. Topical NSAIDs really should be top for treatment.”

In terms of referrals, 92% (n=377) of respondents said that they would refer patients with symptoms of OA to the GP and only 39% (n=158) said they would refer to the physiotherapist.

Chris Hayes, an extended scope physiotherapist based in Lichfield, Staffordshire, said that referral rates to physiotherapy should be higher than this. Dickson added that pharmacists should also consider physical trainers — not necessarily in the NHS but in the gym: “80% of patients will get better themselves — getting fitter would improve things,” he said. However, Conaghan pointed out that while gyms are “potentially a good course”, he would have concerns about quality and pharmacists would need to know locally which gyms are safe to refer patients to.

Just 11% (n=43) of respondents to the survey said that their pharmacy team actively managed the treatment of patients with OA as part of a wider multidisciplinary team approach involving GPs, physiotherapists and other relevant healthcare professionals.

Overall, it was agreed that the survey highlighted a baseline level of knowledge of OA among pharmacy teams, but clear variation in practice and little-to-no multidisciplinary team input.

Evidence base

To enable the panel to consider the evidence behind the management of OA, Quicke and Colin Standford, a retired GP and clinical champion for OA, presented research from Keele University.

Quicke shared the results of a trial aiming to evaluate the clinical effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in older adults, compared with usual GP care. In terms of both pain and function, it found that both physiotherapy and pharmacy review showed a significant improvement in the first three months, but that improvement failed to remain significant in the long term. However, NSAID usage was reduced by 15% and, anecdotally, patients were happy with the access they had to the pharmacy.

Standford presented a project aiming to determine the effect of a model OA consultation, informed by core NICE OA guidelines, to support self-management in adults aged 45 years and over with peripheral joint pain. The consultation included promotion of a patient OA guidebook, developed by Keele University in partnership with Arthritis Research UK and NIHR.

It was found that although there was not any clinical difference in primary outcomes, the consultation improved quality indicators of OA care, helped to implement guidelines in primary care, reduced NSAID use and orthopaedic visits, and did not cost any more money.

Finally, the panel was told about the Joint Implementation of Guidelines for Osteoarthritis in Western Europe (JIGSAW-E) which has been developed to support primary care in five European countries to address the unmet needs of adults consulting for OA, with initial pilots in the West Midlands.

The rationale behind the implementation of JIGSAW-E in pharmacy was to widen the public’s knowledge of OA before they seek help from their GP or practice nurse; to change the culture about OA; to engage patients in the concept of self-management or self-help; and to effect better collaboration between pharmacy and GP services.

Standford stated that the whole culture around OA needs to be challenged — both among medical staff and the public to promote better self-care strategies. The panel agreed and Williams noted that best practice for OA should always be evidence led and patient centred. “What are the patient’s priorities — to have a good night’s sleep? Walk with grandchildren in the park? What helps improve their quality of life? Their experience will always be subjective,” he explained.

Conaghan concurred and said that pharmacy-based care for OA needs to be personalised and tailored to help individual patients achieve what they want, and it was agreed that simplicity is key to this. “Signposting to safe websites, simple exercises they could be handing out, local signposting — we’ve got to get people stronger, into their local parks and pools,” he said. “Patients don’t like going from one clinician to another, they would rather have one person tell them about the whole package,” Doherty added.

As a result, the panel agreed to draft a referral pathway to direct pharmacists in the management of their patients.

It was agreed that pharmacy could play a valuable role in the management and identification of OA; however, the necessary training and education for this role must be recognised and the individual roles of the pharmacy team need to be defined. “You can have all the guidelines and formularies in the world, but if you don’t know which does it all you won’t use them,” Dickson noted.

“Without having published research and raising questions, there is nothing to change practice — we need to work with professional bodies to develop guidance to inform practice,” Williams added.

Conaghan emphasised that developing a high-quality pathway, backed by the RPS, would reassure pharmacists in dealing with patients in this area.

To build on the learning from this event, The Pharmaceutical Journal will be developing a supplement containing relevant learning content, features and an infographic to help guide joint pain management in community pharmacy settings.

Citation: 
The Pharmaceutical Journal, February 2019, online. DOI: 10.1211/PJ.2019.20205666