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

Addressing the learning needs of pharmacy teams to enhance and standardise care of patients who present with joint pain in community pharmacy. Source: MAG / The Pharmaceutical Journal The interdisciplinary panel of experts including pharmacists, GPs, rheumatologist and patient group representative, standing from left: Alastair Dickson, Angela Kam, Philip Conaghan, Paul Bennett, Ash Soni, Thomas Richard, Martin Lau, Ade Williams and Michael Doherty. Sitting from left: Johny Quicke, Colin Stanford, James Alman, Marisa Maciborka and Chris Hayes

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.

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.”

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.

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.

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 […]

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