Chief Pharmacist and Head of Pharmacy Services at Care UK (NHS)
Pharmacy Services at Care UK (NHS)
Dr Yousaf Ahmad is a senior health executive with over 15 years of experience evaluating clinical medications, with specialist experience in pain management, evaluating oncology products, palliative care, and automation. He is the current Chief Pharmacist and Head of Pharmacy Services at Care UK (NHS) and sits on multiple national committees including; NICE, Royal Pharmaceutical Society and a Specialist Committee Member for Pain on the UK Clinical Pharmacy Association.
Section 1: The Current Treatment Landscape
1.1. What is chronic pain?
Chronic pain is a term that has been around probably since 1980, 1985 and it’s categorized by a sense of an emotional outcome of a patient suffering from externally caused pain. But more importantly, the chronic pain definition from the International Association of Pain indicates that chronic pain is a pain symptom that’s felt over a period of time.
The arbitrary period of time is three months, coined by the International Association for the Study of Pain. So chronic pain is any pain suffered longer than three months and the rationale behind that is that before three months, most pain and most causes of pain should resolve. What we find is that acute pain or any new type of pain, such as if you have a broken arm, should resolve before the three month gap. After three months, any lasting pain usually, is associated with functional disability, emotional distress, but more so based on a condition that hasn’t yet manifested itself. We define that pain now as chronic pain.
1.1.1. What is chronic primary pain? And what is the difference between them?
Chronic pain itself has many different syndromes. And within that there’s a new terminology, called chronic primary pain. And chronic primary pain is what I’m seeing as the new terminology to chronic pain.
Chronic primary pain and chronic pain are synonymous with each other, it’s just a new terminology, which we see quite often in research and in guidelines, such as the NICE guidelines. We use chronic pain or use the other vernacular of chronic primary pain, so they’re not too dissimilar.
People in clinical environments indicate that, chronic primary pain is more or less an umbrella term to encompass all types of chronic pain conditions. Conditions such as fibromyalgia, complex regional pain, migraine, IBS, nonspecific lower back pain, musculoskeletal pain, neuropathic pain, all those terms are under the chronic primary pain banner. But just to give you the high level, chronic pain and chronic primary pain the same nomenclature.
1.2. What is the established practice of treating patients with chronic pain?
The majority of patients that have any degree of chronic pain are managed by primary care physicians, namely the GP as most pain that lasts for a longer period of time. Most patients are likely to go to their GP, more than any other healthcare professional to help them manage that chronic pain. And what we quickly see is that for a period of 0-18 months, the patient goes back and forward to the GP to obtain relevant pharmacological treatment for their pain.
Pain management has a number of different avenues, both pharmacological and non-pharmacological. But what we find is inherently a majority of patients that have any degree of chronic pain, be it mild, moderate, severe, be it a diagnosed condition or not, typically are managed in the first instance by the GP.
What we are seeing now, is that in the primary care sphere, there are several other professionals involved in managing a patient’s pain, typically a pharmacist or a nurse or any other allied healthcare professionals. Moreover, what we’re seeing in the primary care setting, is that Physios now get more involved early on in managing chronic pain patients. What we know is that it is useful, but unfortunately, the majority of patients that are managed in primary care are either managed poorly because of either access; or education of professionals about managing pain; or the fact that they spend too much time in primary care and not getting referred sooner.
1.2.1. How many chronic patients experience this treatment?
Blair Smith did a study quite recently, where the number of patients living with some degree of pain is one in five. 20% in the UK are living with some degree of pain. Of that 20%, around 33.3% to probably 40% have some degree of chronic pain. So what we find is a large number of people within that one in five have established chronic pain.
So there’s a large number of people that have chronic pain and within those chronic pain sufferers the severity does vary. Within primary care, I would say at least 70% to 80% of those chronic pain patients are managed there concurrently. And between 20% to 30% are managed by specialist physicians in the hospital. The majority of patients with chronic pain that need specialists don’t get it, and those that do get it, there’s still only a fifth, to potentially a third, or less than a third that are under specialist care.
1.3. Do patients expect painkillers as part of their treatment?
Absolutely, I think there’s definitely a psychology around the expectations of a patient in studies I have read. I think this is not just synonymous with chronic pain, but any GP consultation. There is an expectation that the patient will leave with something, and that something could be a prescription for medicines; or be signposting to another healthcare professional; or referral to another clinician. But they have to leave with something.
Unfortunately with chronic pain, we over-medicalize the patient. We give them painkillers, and sometimes rightly and wrongly, we give them painkillers too early. Furthermore we use painkillers in an uneducated way. In primary care, we reach for painkillers and pharmacological measures too early, and we don’t use other techniques such as psychosocial measures, or through things like physio and acupuncture.
And there are reasons for this. Some GPs may say, “I don’t have access to them. I don’t have them in my area at all. I’m not paid to defer onto them, my commissioning and payment structure isn’t tied to that.” So there’s many other connotations that many GPs will give you to say that’s the reason we don’t go there. But for me that doesn’t cut the mustard, because what we’re doing is that we are managing this type of patient in completely the wrong manner.
1.4. How effective have pharmacological treatments been in treating chronic pain?
1.4.1. Quality of Life
There are pharmacological treatments in chronic pain that originated from anti-psychotics, such as neuropathic agents, the gabapentinoids or some of the tricyclic agents, such as Amitriptyline, which inherently have an impact on our degree of pain. They also have an impact on cognitive and mental status. There are nuances between different patients, but overall I think the improvement of quality of life, only goes up by a couple of percentage points to maybe 10% to 15%, because ultimately, what we know is that if that medication isn’t used appropriately, i.e., titration, initiation, stoppage, when the impact of chronic pain is low. But equally what that also means is that poorly controlled chronic pain equates to poorly controlled mental status.
When we use drugs in an uneducated way, the impact to quality of life is slim, because what we’re finding is that the chronic pain element is still there. Thus, the impact to your life is still there, therfore the impact to any cognitive improvement is low.
What we find in specialist settings, is perhaps a better use of all the pharmacy. So, use of the right drug, with the right mental health and modality, and also other non-pharmacological treatments, that combination typically has a better outcome. I think it’s highly dependent on the setting that the patient is in. It’s also highly dependent on the severity of the chronic pain. And thirdly, I think it’s dependent on how educated the patients are.
Chronic pain patients typically are one of the most educated in terms of any syndrome, both in terms of how to lobby politicians, but also in terms of how educated they are. Once they’re more educated in the appropriate way of managing pain, they’re able to rationalize their treatment, and therefore have a positive subconscious impact on their chronic pain. Which is absolutely a fascinating paradigm. What we are able to do with an educated pain patient is take them off medications, scale back their therapy, and have a more positive impact on their chronic pain, which is a very unusual dichotomy, but in specialist settings, that’s what we see happen.
1.4.3. Regain Physical Function
What we find is pharmacologic treatments are a stepping stone to allow patients to get back to some degree of functionality. That’s mainly physical functionality, and mental or cognitive functionality. There are many cases, where we give patients strong painkillers, which are fast acting just to get them moving, because the act of moving really has a positive impact in the overall pain. So, I would say pharmacological treatments are very good to improve functionality, but sometimes it comes at the cost of decreasing their cognitive functionality.
One of the first goals is functionality improvement, because typical current pain management practices tells us once we get patients moving that ultimately we’re mobilizing their pain receptors to interpret pain differently.
The primary aim and outcome is to get patients moving. But that does change after patients are either seen by a specialist, or potentially two years down the road because functionality then becomes just another part of the overall pain. We want patients to ultimately have a biopsychosocial model of care; meaning that we were able to anatomically physically care for them; their psychological impact; but then also their environmental, societal impact, all those three things are the golden triangle at managing chronic pain patients well. So we see functionality being lesser important, but also part of the wider part of the current pain management.
Section 2: Alternative Chronic Pain Therapies
2.1. The Alternative Chronic Pain Management Therapies
2.1.1. Electromagnetic Therapy
Electromagnetic therapy is basically a TENS machine. It is an electronic machine, which zaps electricity to the part of the body that is suffering pain. That is good for patients with neuropathic pain, and it helps to neuro-modulate or re-modulate the pain receptors in that area and it is a physical nonpharmacological intervention which has been in part of our arsenal for a long period of time. The evidence base is sketchy but what we find is that it’s very useful to trial in patients and some patients get extreme benefit from it. We also find ultrasound therapy. So again, using waves to re-modulate pain receptors. As another experimental therapy I would say ultrasound is compared to TENS.
2.1.2. Allied Healthcare Professionals
Another approach is around allied health care professionals, such as the use of Physios, the use of exercise, CBT (cognitive behavioral therapy) and the use of education. The nonpharmacological allied healthcare professional goal is absolutely an emerging market. These are programs which focus on reeducating chronic pain patients and are becoming the staple of any successful pain clinic in a specialized setting.
They’re trying to teach them to understand pain in a different way. For example, to understand how to live with pain, to self manage with pain, and to tell them that chronic pain is actually an incurable disease. It is trying to re-picture in a patient’s brain what chronic pain is to them.
Secondly, is to use CBT, to try to build up chronic pain patients to some degree of normality. For example;
Doing small short exercises for small short periods of time and building upon that.
Using techniques which are synonymous with health and psychology to build patients up.
Thirdly, is to tell patients the importance of their own psyche in managing chronic pain, to make sure that they use every part of the chronic pain arsenal and not just focus on one. So not just focus on medicine, they use every one just as important.
The health psychology or a proper in-house psychology, is about getting into the mindset of chronic pain patients, both to help their pain, but also to help their mental status. Because what we do know, and evidence is clearly out there, is that chronic pain patients are nearly twice or three times more likely to have a mental health disease than someone that doesn’t have chronic pain.
We find that psychosocial support is absolute necessity if you want to manage chronic pain patients.
There are some more experiential ones such as the ultrasound waves and laser therapy are coming. There’s also another one, which is called craniotomy, which is a uncommon surgical intervention, where they cut the carotid artery, which is more synonymous with pain management. It’s almost as if they get to a stage where a chronic pain patient severs any ability to feel pain. I’ve seen two or three cases in my tenure, but that’s also another real severe nonpharmacological treatment, and we might be seeing more research in going forward.
2.2. What is the most effective non-pharmacological approach to treating chronic pain?
We believed that psychology and pharmacological treatments were the best way to manage pain patients and that was perhaps the thought process in the early 90s. I would say in the last decade to 15 years, we have seen, that to manage chronic pain patients, you actually need the whole collegiate response. Both in terms of medicines, some of the nonpharmacological ones and the allied health care professionals, all of them are vitally important and I don’t think it would be sensible to outweigh one over the other. I think they’re all vitally important.
2.3. What are the challenges to delivering a coordinated chronic pain programme?
I think there is a certain order to coordination as well. If a patient hasn’t gone through the pain management program, they wouldn’t really understand the process so there’s no point doing a pain management program after they’ve completed 10 sessions with a psychologist. There is a process to it, and coordinating that process is extremely difficult and sometimes we don’t get the full benefit of the collegiate arsenal of therapies, because a patient has entered the system somewhere else; or they’ve spent too long in one area and not moved on, so it is a difficult aspect.
I think the absolute golden thread here would be to deliver something like this in a non-specialist setting. That is where we want to get to. It takes a while for patients to reach specialist care and when they are there, it can take a while to go through the system.
So what we want to deliver is that specialist care in a non-specialist setting. So that number that’s in primary care, that 70% to 80% of patients with chronic pain in primary care, we want to be able to deliver that level of service in that setting. I think there needs to be a number of things to happen in order to reach those patients sitting in primary care.
Currently we have the split systems. We have private or commission systems that only have half of the services, and so we find GPs that have access to a Physio, but don’t have access to a psychologist. We have GPs that have access to a pain management program delivered by the NHS trust, but they don’t have access to anything else. We have private providers that are doing the pain management program, but they won’t do anything else.
So it’s quite desperate at the moment. There needs to be a coherent strategy in managing chronic pain patients in a non-specialist setting, and it has to be backed with a financial commissioning from a centralized government or a centralized NHS system and then tendered out to deliver. I’m in favor of it being fully delivered by the NHS. But I’m also understanding that sometimes we need private providers to provide coverage. We need to have those steps tendered out with the right commissioning behind it to have any traction at all.
2.4. What would be the impact of withdrawing pharmacological treatment?
I think there would perhaps be a GP contracting revolt, i.e., did they stop getting paid for chronic pain patients? To make change happen, I think there also has to be a health ecosystem question that needs answering. For example, if you look at another chronic condition such as diabetes, we’ve spent a lot of time educating patients through mass public advertisements through to seeing diabetic specialist nurses come into existence. We need the same thing happening in chronic pain to have any traction. We need chronic pain specialists nurses, specialist pharmacists, we need pathways that are dedicated to chronic pain. We need that specialist care delivered in non-specialist settings. And more importantly, we need money and finance around it, to actually get it off the ground.
2.5. What opportunities are there if pharmacological treatments are not available?
I would say it starts us treating chronic pain patients the right way. It forces us to treat patients the right way. For the majority of GPs this won’t be popular, for some it will be because they know the benefit of moving away, but I think GPs are more concerned on the difficult conversations they will have to have with the patients rather than the guidelines. So, their mindset is not in the right frame of mind. They’re worried about the conversation, rather than worrying about what the right thing is to do for the patient. Different GPs probably have different stances, I appreciate that, but it starts that conversation within the healthcare sphere around treating chronic pain patients rightly and moving away from the drugs.