Module 1 June 2012

Chronic Pain – assessment and management in primary care

For use by Healthcare Professionals in the Republic of Ireland only© Copyright 2012 Pfizer Healthcare IrelandDate of Preparation: Module 1 June 2012 EPBU/2012/XXX

Established Products

Educational distance learning content for healthcare professionals in Ireland

Objectives

• Describechronicpain,itsprevalenceandconsequencesofinadequatemanagement

• Identifybarriersinprimarycaretoeffectivediagnosisandassessmentofchronicpainanddevelop

strategiestoovercomethesebarriers

• Discussbothpharmacologicandnon-pharmacologictherapeuticoptionsandbenefitsof

multidisciplinarycare

Introduction

Pain is one of the commonest reasons for patients to seek medical attention.1 A recent survey has shown that as many as 8.3 visits per year to primary care physicians in Ireland were due to symptoms of pain.2 A large scale survey carried out in 15 European countries and Israel in 2006, screening 46,394 respondents reported that the prevalence of chronic pain of moderate to severe intensity in adult Europeans was 19%.3

More recent survey data from another study, carried out in 2,019 people with chronic pain and 1,472 primary care physicians across 15 European countries, have demonstrated that chronic pain affects 12-54% of adult Europeans, and its prevalence in Ireland is up to 13%.2 The PRIME (Prevalence, Impact and Cost of Chronic Pain) study, on the other hand, determined the prevalence of chronic pain to be as high as 35.5% in Ireland.4 The PRIME study was designed to investigate the prevalence of chronic pain in Ireland; compare the psychological and physical health profiles of those with and without chronic pain; and explore pain-related disability.4 Responses to survey questions were obtained from 1,204 people.

Despite the magnitude of the problem, chronic pain is both under-recognised and undertreated in primary care.2,5 Indeed, up to 38% of patients reported being inadequately managed in primary care for their pain symptoms.2 In addition, people with chronic pain reported waiting up to 2.2 years between seeking help and diagnosis, and 1.9 years before their pain was adequately managed.2

Sheehan et al reported in 1996 that the estimated cost of pain for 95 patients to the Irish Health Services when added to the amount of Social Welfare payments received and the lost earnings of each patient amounted to 1.9 million pounds at the time of referral.6 The recent data from PRIME survey show that the mean cost per chronic pain patient is estimated at €5,665 per year across all grades of pain, which was extrapolated to €5.34 billion or 2.86% of Irish GDP per year.7 This demonstrates an urgent need for cost effective strategies to manage chronic pain effectively.

Understanding chronic pain

Chronic pain is defined as pain that outlasts normal healing time (usually three to six months), and is most frequently associated with musculoskeletal disorders such as low back pain and arthritis. However, it can also be associated with other disorders such as depression or metabolic disorders or neurologic conditions such as multiple sclerosis.

Pain (acute or chronic) can be categorised as nociceptive or neuropathic. Nociceptive pain is caused by an active illness, injury and/or inflammatory process associated with actual or potential tissue damage i.e. Nociceptive pain results from activity in neural pathways secondary to actual or potential tissue damage. Nociceptive pain is mediated by pain receptors located in skin, musculoskeletal system, bone, and joints.8 Neuropathic pain, on the other hand, results from direct injury to a peripheral or central sensory nerve; the affected nerves do not produce transduction at nociceptors.8 Pain characteristics and associated conditions for both types of pain are shown in Table 1.

CPD 26: BENIGN PROSTATIC HYPERPLASIA / URINARY INCONTINENCE

Benign Prostatic Hyperplasia

Supported by

60 Second Summary

Benign prostatic hyperplasia (BHP) is a non-malignant enlargement of both connective and glandular tissues of the gland, which restricts the urethra and leads to a reduced flow of urine out of the bladder. BPH is directly related to the ageing process and hormone activity.

The serum prostate specific antigen (PSA), a common screening tool for prostate cancer, is often useful in detecting the progression of BPH. Treatment of the condition includes: conservative management, pharmacological intervention and surgery. Alpha-1 blockers are considered the first line treatment of moderate to severe lower urinary tract symptoms. 5-alpha-reductase inhibitors should be considered for men with moderate to severe lower urinary tract symptoms and the drug of choice for either an enlarged prostate or an elevated PSA level.

No phytotherapeutic agent has been shown to clinically reduce the size of the prostate gland and no trial has proven a reduction of bladder outlet obstruction or decreased disease progression. Pharmacists should encourage men describing symptoms of prostate enlargement to contact their GP for a full prostate check.

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BPH is directly related to the ageing process and hormone activity. No risk factors have been identified other than having normally functioning testicles.1

There are a number of characteristic symptoms of prostate enlargement, including:

• Dribblingattheendofurinating,

• Incontinence,

• Incompleteemptyingofthebladder,

• Difficultystartingtourinate,

• Frequentneedtourinate,particularly at night.

More severe symptoms include pain on urination, urinary retention and blood in the urine.

BPH is non-malignant enlargement of both connective and glandular tissues of

the gland, affecting the transitional zone of the prostate, encircling the urethra and thus leading to restriction of flow out of the bladder. This type of restriction can cause the urine to be retained back up in the bladder, causingincreasedurinaryfrequency,bothdayandnight.Ifleftuntreated,thiscanleadto a complete blockage of the urethra and frequenturinarytractinfections.1, 2

The serum prostate specific antigen (PSA), a common screening tool for prostate cancer, is often useful in detecting the progression of BPH. The predicted PSA level can range from 0ng/ml to 4ng/ml, although this can vary with age and race. Most physicians will recommend a biopsy for levels higher than this, to rule out prostate cancer.

The objectives of the treatment for BPH are symptomatic relief, improved urinary flow and the prevention of long-term complications, such as acute urinary retention and the need for surgery to remove part of the gland. Treatment of the condition includes: conservative management, pharmacological intervention and surgery.

1. REFLECT - Before reading this module, consider the following: Will this clinical area be relevant to my practice.

2. IDENTIFY -Iftheanswerisno,Imaystill be interested in the area but the article may not contribute towards my continuing professionaldevelopment(CPD).Iftheanswerisyes,Ishouldidentifyanyknowledgegapsinthe clinical area.

3. PLAN -IfIhaveidentifiedaknowledgegap

- will this article satisfy those needs - or will morereadingberequired?

4. EVALUATE -Didthisarticlemeetmylearning needs - and how has my practise changedasaresult? HaveIidentifiedfurtherlearningneeds?

5. WHAT NEXT - At this time you may like to record your learning for future use or assessment.Followthe4previoussteps, log and record your findings.

PublishedbyIPNandsupportedwithanunrestricted educational grant from Pfizer HealthcareIreland.Copiescanbedownloadedfrom www.irishpharmacytraining.ie

Disclaimer:AllmaterialpublishedinCPDandthePharmacy is copyright and no part of this can be used within any other publication without the permission of the publishers and author.

Benign prostatic hyperplasia (BPH) is the most common benign tumour in men and most commonly occurs after the age of 60. It is estimated that a small amount of prostate enlargement is present in many men over the age of 40 years and 60% of men over the age of 60 years will have a degree of prostate enlargement. The incidence of BPH is deemed to be so high that it is predicted that all men will have an enlarged prostate should they live long enough.1

Biography - Ronan Sheridan graduated from the Robert Gordon University, Aberdeen in 2009 with a Masters in Pharmacy with Distinction. He worked for three years as a pre-registration and clinical pharmacist at the Chelsea and Westminster Hospital NHS Foundation Trust, London before joining Market Point and Green Road Pharmacy, Mullingar, Co Westmeath as pharmacist/manager. Sheridan was recently awarded the 2012 Helix Health Young Pharmacist of the Year.

Module 1 June 2012

Chronic Pain – assessment and management in primary care

For use by Healthcare Professionals in the Republic of Ireland only© Copyright 2012 Pfizer Healthcare IrelandDate of Preparation: Module 1 June 2012 EPBU/2012/XXX

Established Products

Educational distance learning content for healthcare professionals in Ireland

Objectives

• Describechronicpain,itsprevalenceandconsequencesofinadequatemanagement

• Identifybarriersinprimarycaretoeffectivediagnosisandassessmentofchronicpainanddevelop

strategiestoovercomethesebarriers

• Discussbothpharmacologicandnon-pharmacologictherapeuticoptionsandbenefitsof

multidisciplinarycare

Introduction

Pain is one of the commonest reasons for patients to seek medical attention.1 A recent survey has shown that as many as 8.3 visits per year to primary care physicians in Ireland were due to symptoms of pain.2 A large scale survey carried out in 15 European countries and Israel in 2006, screening 46,394 respondents reported that the prevalence of chronic pain of moderate to severe intensity in adult Europeans was 19%.3

More recent survey data from another study, carried out in 2,019 people with chronic pain and 1,472 primary care physicians across 15 European countries, have demonstrated that chronic pain affects 12-54% of adult Europeans, and its prevalence in Ireland is up to 13%.2 The PRIME (Prevalence, Impact and Cost of Chronic Pain) study, on the other hand, determined the prevalence of chronic pain to be as high as 35.5% in Ireland.4 The PRIME study was designed to investigate the prevalence of chronic pain in Ireland; compare the psychological and physical health profiles of those with and without chronic pain; and explore pain-related disability.4 Responses to survey questions were obtained from 1,204 people.

Despite the magnitude of the problem, chronic pain is both under-recognised and undertreated in primary care.2,5 Indeed, up to 38% of patients reported being inadequately managed in primary care for their pain symptoms.2 In addition, people with chronic pain reported waiting up to 2.2 years between seeking help and diagnosis, and 1.9 years before their pain was adequately managed.2

Sheehan et al reported in 1996 that the estimated cost of pain for 95 patients to the Irish Health Services when added to the amount of Social Welfare payments received and the lost earnings of each patient amounted to 1.9 million pounds at the time of referral.6 The recent data from PRIME survey show that the mean cost per chronic pain patient is estimated at €5,665 per year across all grades of pain, which was extrapolated to €5.34 billion or 2.86% of Irish GDP per year.7 This demonstrates an urgent need for cost effective strategies to manage chronic pain effectively.

Understanding chronic pain

Chronic pain is defined as pain that outlasts normal healing time (usually three to six months), and is most frequently associated with musculoskeletal disorders such as low back pain and arthritis. However, it can also be associated with other disorders such as depression or metabolic disorders or neurologic conditions such as multiple sclerosis.

Pain (acute or chronic) can be categorised as nociceptive or neuropathic. Nociceptive pain is caused by an active illness, injury and/or inflammatory process associated with actual or potential tissue damage i.e. Nociceptive pain results from activity in neural pathways secondary to actual or potential tissue damage. Nociceptive pain is mediated by pain receptors located in skin, musculoskeletal system, bone, and joints.8 Neuropathic pain, on the other hand, results from direct injury to a peripheral or central sensory nerve; the affected nerves do not produce transduction at nociceptors.8 Pain characteristics and associated conditions for both types of pain are shown in Table 1.

CPD 26: BENIGN PROSTATIC HYPERPLASIA / URINARY INCONTINENCE

CONSERVATIVE MANAGEMENT

Formanymenwithlowerurinarytractsymptoms, which are confirmed to be BPH, they may not be any significant discomfort. Forthispatientgroup,itmaybemoresuitable for watchful waiting (WW), which is a policy of care involving education, reassurance, periodic monitoring and lifestyle advice. This type of management is common, withmostmeninitiallybeingofferedthis.Inthe therapeutic cascade, it is regarded as the first tier.1, 3

Lifestyle advice can also be offered as part of conservative management:

• Itisadvisabletourinatewhenanurgeis first felt.

• Itisoftenbeneficialtoattemptpassing urine, even if an urge is not felt.

• Avoidanceormoderationofalcoholand caffeine as these increase fluid output and may have an irritant and diuretic effect.

• Spreadoutfluidintakethroughouttheday. Avoid drinking large volumes of fluids within two hours of bedtime.

• Avoiddecongestantsorantihistamines because these groups of medicines can increase BPH symptoms.

• Coldweatherandlackofphysicalactivity may worsen symptoms, so avoid getting cold, if possible and increase daily exercise.

• Learnandperformkegelexercises(pelvic strengthening exercises).

• Nervousnessandtensioncanleadtomore frequenturination.

• Considerdistractiontechniques,such aspenilesqueeze,breathingexercisesand perineal pressure.

• Referraltospecialisturologynursefor trainingontechniquesforincreasingthe bladder capacity.4, 6

PHARMACOLOGICAL INTERVENTION

• Alpha-1blockers

Alpha-1 blockers are considered the first line treatment of moderate to severe lower urinary tract symptoms. The once-daily dosing helps to improve compliance and, due to the rapid onset of action of alfuzosin and tamsulosin, symptomatic improvements can be seen within days of initiating treatment. They can also be used for intermittent use with fluctuating intensity of symptoms.

They act by inhibiting the effect of noradrenaline on prostate smooth muscle, thus reducing prostate tone and bladder outlet obstruction. The main side effects are asthenia,dizzinessandhypotension.Drugswithin the class include: tamsulosin HCL, alfuzosin HCL, doxazosin mesylate, terazosin HCL.

Ithasbeendemonstratedthatallalpha-1blockers have a similar efficacy in appropriate doses, by indirect comparison. Patients with smaller prostates appear to respond better to alpha-1 blockers in comparison to those with larger glands, across a similar age range.

The efficacy of alpha-1 blockers can be maintained over a long period; however they

do not reduce the size of the gland and do not prevent acute urinary retention.

• 5-alpha-reductaseinhibitors

The 5-alpha-reductase inhibitors should be considered for men with moderate to severe lower urinary tract symptoms and the drug of choice for either an enlarged prostate or an elevated PSA level. They are only suitable for long-term treatment, due to their slow onset of action. They can prevent disease progression, particularly episodes of acute urinary retention and the need for surgery.

The drug acts by shrinking prostate tissue by apoptosis and inhibits the enzyme that converts testosterone to dihydrotestosterone, which reduces testosterone metabolism and, thus reducing the size of the prostate. The reduced size of the prostate helps to improve obstructivesymptoms.Itcantakeseveralmonths before the full effect of symptoms canbeseen.Drugswithintheclassinclude:finasteride, dutasteride.

The most relevant adverse effects of both finasteride and dutasteride are related to sexual function and include reduced libido, erectiledysfunctionand,lessfrequently,ejaculation disorders. These 5-alpha-reductase inhibitors are also teratogenic.

• Muscarinicreceptorantagonists

Muscarinic receptor antagonists are a treatment option in men with moderate to severe lower urinary tract symptoms that have predominantly bladder storage symptoms, independent of bladder outlet obstruction.

This class of drugs decreases the ability of the bladder to contract by blocking the muscarinic receptors on the detrusor muscle, the muscle responsible for the passing ofurine.Drugswithintheclassinclude:fesoterodine fumarate, oxybutynin HCL, propiverine HCL, solifenacin succinate, tolterodine tartrate.

This group of medicines is generally well tolerated with the side effect profile relating to the well-known, peripheral anti-muscarinic adverse effects, such as dryness of the mouth, tachycardia and constipation. The side effects of anti-muscarinics often lead to poor compliance and discontinuation of therapy.

Randomised,placebo-controlledtrialsdemonstrated that tolterodine can significantly reduce urgency incontinence for daytimeor24-hourfrequencycomparedtoplacebo.

• Combinationproducts

1) Alpha1-blockers + muscarinic receptor antagonists

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KEY PHARMACOKINETIC PROPERTIES AND STANDARD DOSES OF ALPHA1-BLOCKERS LICENSED IN EUROPE FOR TREATING SYMPTOMS OF BPH

tmax = time to maximum plasma concentration; t � = elimination half-life; IR = immediate release; SR = sustainedrelease; GITS = Gastrointestinal Therapeutic System; MR = Modified Release; OCAS = Oral Controlled Absorption System.

Supported by

Drug tmax (hours) t½ (hours) Recommended daily doseAlfuzosin IR 1.5 4 3 x 2.5mgAlfuzosin SR 3 8 2 x 5mgAlfuzosin XL 8-9 11 1 x 10mgDoxazosin IR 2-3 20 1x 2-8mgDoxazosin GITS 8-12 20 1 x 4-8mgSilodosin 2-3 14 1 x 4-8mgTamsulosin MR 4-6 14 1x 0.4mgTamsulosin OCAS 4-6 14 1x 0.4mgTerazosin 1-2 10 1 x 5-10mg

1x 1-8mg

Module 1 June 2012

Chronic Pain – assessment and management in primary care

For use by Healthcare Professionals in the Republic of Ireland only© Copyright 2012 Pfizer Healthcare IrelandDate of Preparation: Module 1 June 2012 EPBU/2012/XXX

Established Products

Educational distance learning content for healthcare professionals in Ireland

Objectives

• Describechronicpain,itsprevalenceandconsequencesofinadequatemanagement

• Identifybarriersinprimarycaretoeffectivediagnosisandassessmentofchronicpainanddevelop

strategiestoovercomethesebarriers

• Discussbothpharmacologicandnon-pharmacologictherapeuticoptionsandbenefitsof

multidisciplinarycare

Introduction

Pain is one of the commonest reasons for patients to seek medical attention.1 A recent survey has shown that as many as 8.3 visits per year to primary care physicians in Ireland were due to symptoms of pain.2 A large scale survey carried out in 15 European countries and Israel in 2006, screening 46,394 respondents reported that the prevalence of chronic pain of moderate to severe intensity in adult Europeans was 19%.3

More recent survey data from another study, carried out in 2,019 people with chronic pain and 1,472 primary care physicians across 15 European countries, have demonstrated that chronic pain affects 12-54% of adult Europeans, and its prevalence in Ireland is up to 13%.2 The PRIME (Prevalence, Impact and Cost of Chronic Pain) study, on the other hand, determined the prevalence of chronic pain to be as high as 35.5% in Ireland.4 The PRIME study was designed to investigate the prevalence of chronic pain in Ireland; compare the psychological and physical health profiles of those with and without chronic pain; and explore pain-related disability.4 Responses to survey questions were obtained from 1,204 people.

Despite the magnitude of the problem, chronic pain is both under-recognised and undertreated in primary care.2,5 Indeed, up to 38% of patients reported being inadequately managed in primary care for their pain symptoms.2 In addition, people with chronic pain reported waiting up to 2.2 years between seeking help and diagnosis, and 1.9 years before their pain was adequately managed.2

Sheehan et al reported in 1996 that the estimated cost of pain for 95 patients to the Irish Health Services when added to the amount of Social Welfare payments received and the lost earnings of each patient amounted to 1.9 million pounds at the time of referral.6 The recent data from PRIME survey show that the mean cost per chronic pain patient is estimated at €5,665 per year across all grades of pain, which was extrapolated to €5.34 billion or 2.86% of Irish GDP per year.7 This demonstrates an urgent need for cost effective strategies to manage chronic pain effectively.

Understanding chronic pain

Chronic pain is defined as pain that outlasts normal healing time (usually three to six months), and is most frequently associated with musculoskeletal disorders such as low back pain and arthritis. However, it can also be associated with other disorders such as depression or metabolic disorders or neurologic conditions such as multiple sclerosis.

Pain (acute or chronic) can be categorised as nociceptive or neuropathic. Nociceptive pain is caused by an active illness, injury and/or inflammatory process associated with actual or potential tissue damage i.e. Nociceptive pain results from activity in neural pathways secondary to actual or potential tissue damage. Nociceptive pain is mediated by pain receptors located in skin, musculoskeletal system, bone, and joints.8 Neuropathic pain, on the other hand, results from direct injury to a peripheral or central sensory nerve; the affected nerves do not produce transduction at nociceptors.8 Pain characteristics and associated conditions for both types of pain are shown in Table 1.

Learning, Evaluation, Accredited, Readers, Network | www.learninpharmacy.ie

CPD 26: BENIGN PROSTATIC HYPERPLASIA / URINARY INCONTINENCE

Urinary incontinence is the unintentional passing of urine and is an extremely common complaint in every part of the world. It is estimated that between three and six million people are affected by the condition in the UK alone.2

Urinary Incontinence

Urinary incontinence affects about twice as many women as men, and becomes more common with age. The condition can seriously influence the physical, psychological and social wellbeing of affected individuals.7, 8

The condition can occur as a result of a number of abnormalities of the function of the lower urinary tract or as a result of other illnesses, which tend to cause leakage in different situations. There are a number of different types of urinary incontinence:

• Stressurinaryincontinenceisinvoluntary urine leakage on effort or exertion or on sneezing or coughing.

• Urgeurinaryincontinenceisinvoluntary urine leakage accompanied or immediately preceded by urgency

• Mixedurinaryincontinenceisinvoluntary urine leakage associated with both urgency and exertion, effort, sneezing or coughing.2

Prior to any treatment, it is essential that the urine is assessed to rule out any underlying

infectionsorconditions.Reagentstrip(‘dipstick’) urinalysis may detect infection, proteinuria, haematuria and glycosuria:

• Nitriteandleucocyteesterasemayindicate aUTI.

• Proteinmayindicateinfectionand/orrenal disease.

• Bloodmayindicatemalignancy(or infection).

• Glucosemayindicatediabetesmellitus.

Inclinicalpractice,‘urodynamics’isgenerallyused as a collective term for all tests of bladder and urethral function.2

CONSERVATIVE MANAGEMENT

A number of medical conditions can predispose a patient to urinary incontinence. Such conditions include diseases of the cardiac, respiratory and renal system, as well as diabetes and neurological conditions. These conditions can cause polyuria, nocturia, increased abdominal pressure or CNS disturbances, which lead to

incontinence. Correction or treatment of the underlying condition can help to reduce the severity of the symptoms.

Systemic oestrogen replacement for post-menopausal women with no previous history of incontinence is said to double the incidence of urinary incontinence. Women with previous incontinence are 30% more likely to experience worsening of symptoms.

Recommendationforlifestyleadvice:

• ObesepatientsexperiencingUIshouldbe offered weight reduction programmes to help relieve symptoms.

• Reducingcaffeineintakehelpsreduce urgencyandfrequency,thusimproving symptoms but not incontinence.

• Smokingcessationadviceshouldbe offered as part of a healthy lifestyle, though no evidence suggests smoking cessation improvesUI.

• Patientswithabnormallyhighfluidintake should be advised to modify their daily fluid intake.

Combination treatment with alpha1-blockers and muscarinic receptor antagonist can be considered for patients with moderate to severe lower urinary tract symptoms. Symptom relief should be seen to be insufficient with monotherapy of either drug. Combination treatment is recommended for long term therapy and should be prescribed with caution in men who may have bladder outlet obstruction.

2) Alpha1-blockers + 5a-reductase inhibitors

Combination treatment with alpha1-blockers and 5a-reductase inhibitors should be offered to men with moderate to severe lower urinary tract symptoms, together with an enlarged prostate and a high probability of disease progression. Combination treatment is recommended for long-term therapy.

• Alternativemedicines

The efficacy of plant extracts vary, although

no phytotherapeutic agent has been shown to clinically reduce the size of the prostate gland and no trial has proven reduction of bladder outlet obstruction or decreased disease progression. Some of the agents used include: cucurbita pepo (pumpkin seeds), saw palmetto, hypoxis rooperi (South African star grass), pygeum africanum (bark of the African plum tree), secale cereale (rye pollen), urtica dioica (roots of the stinging nettle).

Currently, the committee of European Association of Urology is unable to recommend any of the above mentioned agents for the treatment of lower urinary tract symptoms, due to the heterogeneity of the agents and the methodological problems with meta-analyses.1

ROLE OF THE PHARMACIST

• Reviewmedicationandoptimisethetime of administration. Consider substituting

drugs with known urinary symptoms for those that cause fewer symptoms.

• Offeradviceonavoidanceof decongestants and antihistamines, as these groups of medicines can increase BPH symptoms.

• Watchforreportsoffallswiththeelderly; this can be a sign of hypotension, and may merit a change in therapy.

• Encouragemendescribingsymptomsof prostate enlargement to contact their GP for a full prostate check.

• Patientsshouldbeencouragedtoreturn to their GP every six months to discuss their symptoms and rule out the need for surgical intervention.

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CPD 26: BENIGN PROSTATIC HYPERPLASIA / URINARY INCONTINENCE

PfizerHealthcareIrelandarecommittedto supporting the continuous professional developmentofpharmacistsinIreland.WearedelightedtobepartneringwithIrishPharmacy News in order to succeed with this.

Throughouttheyear,IrishPharmacyNews will deliver 12 separate modules of continuous professional development, across a wide range of therapy areas. These topics are chosen to support the more common interactions with pharmacy patients, and to optimise the patient experience with retail pharmacy.

We began the 2011 programme with a section on the Gastrointestinal System. OthertopicsincludeDiabetes(TypesIandII),theCardiovascularSystem,SmokingCessation,Infections,Parkinson’sDisease,Alzheimer’sDisease,Depressionandothers.Wehopeyouwillfindvalueinalltopics.

Pfizer’ssupportofthisprogrammeisthe latest element in a range of activities designedtobenefitretailpharmacy.Otherinitiatives include the Multilingual Pharmacy Tool, a tailored Medical Communications Programme, Educational Meetings and Grants,ourPatientInformationPack,newpharmacyConsultationRoombrochuresandother patient-assist programmes including the Quit with Help programme and www.mysterypain.ie.

Ifyouwouldlikeadditionalinformationonany of these pharmacy programmes, please contactPfizerHealthcareIrelandon 01-4676500 and ask for the Established Products Business Unit.

EPBU/2013/008/1

• Thereisaconsistentassociation between a history of constipation and the developmentofUI,thereforealwaystreat constipation and prevent reoccurrence.

• Counselfemaleathletesexperiencing urinary incontinence with intense physical activity that it will not predispose to urinary incontinence in later life.7, 8

PHARMACOLOGICAL INTERVENTION

Antimuscarinics are the drug of choice for patients with persistent urinary incontinence, despite lifestyle interventions. They act by blocking muscarinic receptors in the bladder wall.

The antimuscarinic oxybutynin is the mainstay of treatment for incontinence. This drug offers maximum dosage flexibility but carries a greater risk of side effects, due to its higher plasma peak levels. A systematic review and meta-analysis by Chapple et al. in 2008, which updated previous reviews, showed that oxybutynin versus placebo was betterforimprovementandcureofUI.2

ROLE OF THE PHARMACIST

• Informwomenstartingsystemicoestrogen replacement therapy that it may cause

urinary incontinence, or worsen current symptoms.

• Advisepatientstoavoidanyknown precipitants that may contribute to their symptoms.

• Discussfluidintakeandavoidanceof drinking excess fluids too late in the evening.

• Offerweightmanagementadviceto overweight patients.

• Offersmokingcessationadvice,aspartof healthy living advice.

REFERENCES

1.OelkeMetal.EAUGuidelinesonthe management of male lower urinary tract symptoms, incl. Benign prostatic Obstruction.

2.ChappleCR,RoehrbornCG.Ashiftedparadigm for the further understanding, evaluation, and treatment of lower urinary tract symptoms in men: focus on the bladder. Eur Urol 2006 Apr;49 (4):651-8.

3. Lucas, M et al. EAU Guidelines on Assessment and Nonsurgical Management of

UrinaryIncontinence.EurUrol(2012)http://dx.doi.org/10.1016/j.eururo.2012.08.047

4.StohrerM,BlokB,Castro-DiazD,etal.EAU guidelines on neurogenic lower urinary tract dysfunction. Eur Urol 2009;56: 81–8.

5.IsaacsJT.Importanceofthenaturalhistory of benign prostatic hyperplasia in the evaluation of pharmacologic intervention. Prostate 1990;3(Suppl):1-7.

6.BrownCT,YapT,CromwellDA,etal.Self-management for men with lower urinary tract symptoms – a randomised controlled trial. BMJ2007Jan6;334(7583):25.

7.NationalInstituteofClinicalExcellence.Lower urinary tract symptoms: The management of lower urinary tract symptoms in men, 2010

8.NationalInstituteofClinicalExcellence.Lower urinary tract symptoms: The management of lower urinary tract symptoms in females, 2006.

Module 1 June 2012

Chronic Pain – assessment and management in primary care

For use by Healthcare Professionals in the Republic of Ireland only© Copyright 2012 Pfizer Healthcare IrelandDate of Preparation: Module 1 June 2012 EPBU/2012/XXX

Established Products

Educational distance learning content for healthcare professionals in Ireland

Objectives

• Describechronicpain,itsprevalenceandconsequencesofinadequatemanagement

• Identifybarriersinprimarycaretoeffectivediagnosisandassessmentofchronicpainanddevelop

strategiestoovercomethesebarriers

• Discussbothpharmacologicandnon-pharmacologictherapeuticoptionsandbenefitsof

multidisciplinarycare

Introduction

Pain is one of the commonest reasons for patients to seek medical attention.1 A recent survey has shown that as many as 8.3 visits per year to primary care physicians in Ireland were due to symptoms of pain.2 A large scale survey carried out in 15 European countries and Israel in 2006, screening 46,394 respondents reported that the prevalence of chronic pain of moderate to severe intensity in adult Europeans was 19%.3

More recent survey data from another study, carried out in 2,019 people with chronic pain and 1,472 primary care physicians across 15 European countries, have demonstrated that chronic pain affects 12-54% of adult Europeans, and its prevalence in Ireland is up to 13%.2 The PRIME (Prevalence, Impact and Cost of Chronic Pain) study, on the other hand, determined the prevalence of chronic pain to be as high as 35.5% in Ireland.4 The PRIME study was designed to investigate the prevalence of chronic pain in Ireland; compare the psychological and physical health profiles of those with and without chronic pain; and explore pain-related disability.4 Responses to survey questions were obtained from 1,204 people.

Despite the magnitude of the problem, chronic pain is both under-recognised and undertreated in primary care.2,5 Indeed, up to 38% of patients reported being inadequately managed in primary care for their pain symptoms.2 In addition, people with chronic pain reported waiting up to 2.2 years between seeking help and diagnosis, and 1.9 years before their pain was adequately managed.2

Sheehan et al reported in 1996 that the estimated cost of pain for 95 patients to the Irish Health Services when added to the amount of Social Welfare payments received and the lost earnings of each patient amounted to 1.9 million pounds at the time of referral.6 The recent data from PRIME survey show that the mean cost per chronic pain patient is estimated at €5,665 per year across all grades of pain, which was extrapolated to €5.34 billion or 2.86% of Irish GDP per year.7 This demonstrates an urgent need for cost effective strategies to manage chronic pain effectively.

Understanding chronic pain

Chronic pain is defined as pain that outlasts normal healing time (usually three to six months), and is most frequently associated with musculoskeletal disorders such as low back pain and arthritis. However, it can also be associated with other disorders such as depression or metabolic disorders or neurologic conditions such as multiple sclerosis.

Pain (acute or chronic) can be categorised as nociceptive or neuropathic. Nociceptive pain is caused by an active illness, injury and/or inflammatory process associated with actual or potential tissue damage i.e. Nociceptive pain results from activity in neural pathways secondary to actual or potential tissue damage. Nociceptive pain is mediated by pain receptors located in skin, musculoskeletal system, bone, and joints.8 Neuropathic pain, on the other hand, results from direct injury to a peripheral or central sensory nerve; the affected nerves do not produce transduction at nociceptors.8 Pain characteristics and associated conditions for both types of pain are shown in Table 1.

Supported by