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When pain strikes, many people will visit a community pharmacy for advice. In November 2022, a survey of pharmacy customers in the East Midlands, by the School of Pharmacy at the University of Nottingham, found that 84.8 per cent of customers had previously purchased a pain medicine from the pharmacy counter, around half had used a community pharmacy to get advice about a pain medicine, and slightly fewer had used a community pharmacy for advice about a painful condition.
However, more recent research by Deep Relief has found that 75 per cent of people try to mask the muscle or joint pain they’re experiencing, and 31 per cent do so because they believe this makes the pain less severe. “The majority of people (92 per cent) have told us that they believe there should be more understanding of joint and muscle pain,” says Dr Gill Jenkins, GP and Deep Relief expert hub member. “We need to get the message out there not to ignore it and that there is plenty we can do to help ourselves.”
Pain can affect any part of the body and may be classified as: acute (short-term); chronic (long-term); neuropathic (affecting the nerves); nociceptive (usually associated with inflammation); and nociplastic (increased pain sensitivity). Many chronic pain conditions involve more than one type of pain, with overlap between neuropathic, nociceptive and nociplastic pain.
When advising customers, pharmacy teams should focus on finding out where the pain is, when it started (and how it started, if known), what it feels like (stabbing, aching etc.) and its intensity. It’s also important to know how much impact the pain is having on a customer’s daily life and how it’s affecting their mood.
Not so (a)cute
Acute pain usually starts suddenly and lasts for under three months. It acts as a warning sign that the body may be in danger, such as pain from touching a hot surface or toothache from underlying decay. Acute pain may also be caused by soft tissue damage, such as a strained muscle.
“Acute pain is your sharp, high-intensity pain that normally involves a high level of inflammation,” says Tim Allardyce, physiotherapist from Surrey Physio (surreyphysio.co.uk). “For example, you might sprain your ankle if you have stepped awkwardly, or someone impacted your knee on the football field. This often results in localised swelling and severe pain, often unable to put weight or stress through the joint or muscle.”
Most acute injuries can be treated safely at home by following the PRICE principle: Protect; Rest; Ice; Compression; Elevation. Topical analgesics rubbed into the skin may help to ease mild localised pain, but oral painkillers such as paracetamol or ibuprofen may be more effective for more severe or widespread injuries. Some people benefit from using cold or hot products, such as patches or sprays, too. If acute pain isn’t managed appropriately, it can progress to chronic pain.
“As a general rule of thumb, protect the area and don’t use it too much,” says Tim. “Let the body heal and give the body rest or gentle mobility. The acute phase might last for up to two weeks and will hopefully settle. If the pain doesn’t settle, seek medical attention.”
Longer lasting
Chronic pain is pain that lasts for three months or more and often affects joints and muscles. It may be mild or severe and come and go, or it may be continuous. Everyone is affected differently, but chronic pain may affect daily activities, sleep and mental health.
“Chronic pain, sometimes called persistent pain, is when our body should recover but for some reason it doesn’t,” says Tim. “When we get injured, we often feel pain due to inflammation. In many cases, our body will heal and we’ll be just fine. Sometimes, especially with back pain, things can become chronic, and our body stays in pain for longer. The best way to manage this is to seek help from a physiotherapist or osteopath.”
Osteoarthritis is the most common type of arthritis in the UK, causing pain, stiffness and swelling of the joints. According to the NICE guideline on osteoarthritis management, published in October 2022, the first-line treatment approach should be tailored exercises along with weight management (if appropriate). Topical non-steroidal anti-inflammatory drugs (NSAIDs) are the first choice of pain relief, especially for knee arthritis. If customers are taking oral NSAIDs regularly for chronic pain, they should also be taking a proton pump inhibitor to reduce the risk of gastric bleeding. Other pharmacy treatments, such as glucosamine, rubefacients and herbal products aren’t recommended by NICE guidelines, but some people find these are effective. Cognitive behavioural therapy may also help with chronic pain, and walking aids may improve mobility.
“It’s also important to know how much impact the pain is having on a customer’s daily life and how it’s affecting their mood”
Hit a nerve
Neuropathic pain is caused by damage to the nervous system. This may feel like a constant burning or gnawing pain, or a sharp stabbing pain that comes and goes. Some people also experience itching or numbness. Neuropathic pain may be triggered by normal activities, or no activities at all – even being lightly touched may trigger neuropathic pain in some people.
Sciatica is a type of localised neuropathic pain in which the sciatic nerve (which runs from the lower back to the feet) is irritated or compressed. “The key thing is to identify where the nerve is trapped, or pinched,” says Tim. “This may require further investigation such as an MRI scan. Once the offending nerve has been identified, patients can progress with treatment options including physiotherapy, osteopathy or injection therapy.”
Neuropathic pain may also be triggered by chemotherapy or diabetes or follow an acute shingles infection (called postherpetic neuralgia). Around one in five people with shingles develop postherpetic neuralgia in the area of skin that was affected by the shingles rash.
Postherpetic neuralgia is more likely to affect people over 50, although it’s not clear exactly what increases the risk. The condition can be very painful, and over-the-counter (OTC) painkillers aren’t usually strong enough to ease it. However, some GPs may suggest paracetamol or a paracetamol-codeine combination initially to see if these are effective. Tricyclic antidepressants (such as amitriptyline) or certain antiepileptic medicines (such as pregabalin or gabapentin) are the main prescribed treatments. A GP may also prescribe self-adhesive lidocaine plasters or low-dose capsaicin cream for milder cases or as additional pain relief to use with oral medicines. Other treatments are available from specialist pain clinics, such as higher-strength capsaicin patches. Most people with postherpetic neuralgia usually make a full recovery within a year.
General management advice for postherpetic neuralgia includes wearing loose-fitting cotton or silk clothing as this usually causes less irritation, using cold packs or having a cool bath, and covering the painful area with a plastic wound dressing or several layers of cling film to protect it. If itching is a significant problem, an antihistamine taken at bedtime may help people sleep.
A little overdone
Nociceptive pain is a form of neuropathic pain that involves actual or perceived damage to body tissues, rather than to the nervous system. Tiny nerve endings are activated by an external injury (such as a cut or bruise) or an internal cause (such as inflammation), and then send pain messages to the brain and central nervous system.
Repetitive movements, such as typing, using a computer mouse or playing certain sports such as tennis or golf, may cause repetitive strain injury (RSI). RSI pain is often accompanied by stiffness, tingling, numbness, cramping and swelling. Most nociceptive pain responds well to OTC painkillers, along with physiotherapy to strengthen and stretch the affected muscles or joints. Electrical stimulation (such as TENS machines), acupuncture and yoga may also help. In severe cases, surgery may be needed.
“Repetitive overuse causes inflammation when the load applied to the tissues is too high for what the tissues can cope with,” says Tim. “An example would be a tennis player playing regularly but getting tennis elbow pain on their elbow. A period of rest or reduction in load is needed. Once their symptoms settle, the next stage is to increase the load slowly to the tendon or joint, to allow the tissues to cope with the added load. This is achieved through exercise.”
Put through the paces
Nociplastic pain is caused by increased pain sensitivity without any evidence of tissue damage or inflammation. This type of neuropathic pain is more common in women than in men and may be part of a chronic pain condition, such as fibromyalgia (see page 4), chronic back pain, irritable bowel syndrome, chronic headache and facial pain, and chronic bladder syndrome. Associated symptoms include fatigue, poor sleep and memory or concentration problems. Stress and other nervous system stimulators, such as intense light and noise, may make nociplastic pain worse.
“Pain can occur for many reasons, but the key thing is that the way our bodies interpret pain varies,” says Tim. “For example, one person could bang their elbow against a wall and have pain for three minutes. Someone else could bang their elbow against a wall at the same speed and position and have pain for two to three weeks. This is due to a complex process of how pain is interpreted in our bodies and nervous systems.”
Fibromyalgia is the most common type of nociplastic pain but can be tricky to diagnose. This chronic pain syndrome is also difficult to treat with conventional painkillers, but lifestyle changes, exercise programmes and pacing techniques, along with psychological treatments (such as cognitive behavioural therapy), may help. Drug treatments include tricyclic antidepressants, pregabalin and gabapentin, and many patients with severe symptoms are referred to specialist pain clinics.
Mark it a TENS
Transcutaneous electrical nerve stimulation (TENS) machines can be used to ease acute and chronic pain, such as in arthritis and sports injuries. The lightweight battery-operated devices produce gentle electrical impulses that reduce pain signals travelling to the spinal cord and brain. They may also help to relax muscles, improve blood circulation and stimulate the production of endorphins, which are the body’s natural painkillers.
TENS machines are small enough to be held in one hand or put into a pocket. Wires from the machine are connected to replaceable pads called electrodes. The pads should be placed on clean, dry and healthy skin around the painful area, at least 2.5cm apart. When the machine is switched on, it delivers mild electrical impulses through the pads – felt as a tingling or buzzing sensation. Using a knob or dial, people can control the strength of the electrical impulses, beginning with the lowest setting and gradually increasing it until the sensation feels strong but not uncomfortable. Some machines have different settings, such as ‘pulse’ and ‘continuous’.
TENS isn’t a cure, doesn’t help everyone and only gives short-term relief. But it’s often recommended by healthcare professionals such as physiotherapists or GPs. Pharmacy customers should speak to their GP first if they have a pacemaker or another electrical or metal implant, are pregnant, have epilepsy, blood clots in their legs, cancer or a heart problem, or have an overactive bladder. TENS machines shouldn’t be used when driving, operating machinery, sleeping, or in the bath or shower. The pads shouldn’t be placed on the forehead, mouth, eyes or front of the neck (carotid artery), on the chest and upper back at the same time, over varicose veins or on irritated, infected, broken or numb skin. In some people, the pads can cause an allergy, making the skin red and irritated.
Some specialist pain clinics have TENS machines for patients to try, but pharmacy customers may prefer to buy their own device. Expensive machines aren’t necessarily more effective than the cheaper ones. Recommendation from a healthcare professional is important, along with advice on using the machine effectively and safely.
TENS machines can be used to ease acute and chronic pain.
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