With pain being one of the most common reasons for people to visit a pharmacy, it's important that staff understand the different types of pain and the most effective treatments for them so they can effectively answer frequently asked queries

Pain can have a major impact on a person’s daily life, whether it’s an acute episode such as a headache, or a chronic condition such as arthritis. GlaxoSmithKline Consumer Healthcare recently launched The Global Pain Index (GPI) – a first-of-its-kind global consumer study into attitudes towards body pain around the world. Commissioned on behalf of Voltarol, the study revealed that not only do 93 per cent of people in the UK experience body pain, but they are looking for over-the-counter (OTC) medicated and non-medicated relief. This means that pharmacy staff have a crucial role to play in advising customers on pain-relieving products, as well as selfhelp measures. However, according to Nurofen, some people aren’t treating their pain at all, while others aren’t choosing right products.

Different types of pain need different approaches, yet many people aren’t aware of this. This presents a key opportunity for pharmacy staff to engage in conversations with customers and recommend the right approach to suit their needs.

Q: I suffer from occasional knee pain. Why can I no longer buy diclofenac tablets from my pharmacy? Is there an effective OTC alternative?

A: Diclofenac is a non-steroidal anti-inflammatory drug (NSAID). It’s often recommended for painful conditions such as arthritis, gout, migraine attacks, dental pain, sprains and strains and pain after surgery. In January 2015, the Medicines and Healthcare products Regulatory Agency (MHRA) announced that people would no longer be able to buy diclofenac tablets over the counter. This is due to a “small risk” of heart problems, especially when the medicine is taken in high doses and long-term. Customers now need to have their risk of heart problems assessed before a doctor will prescribe diclofenac tablets.

“If patients have recently bought diclofenac tablets from their pharmacy and continue to need pain relief, they should talk to their pharmacist about suitable alternative treatments,” says Dr Sarah Branch, MHRA’s deputy director for vigilance and risk management of medicines. “However, there is no problem if they wish to stop taking diclofenac in the meantime. People who have been prescribed diclofenac from their doctor should continue to take their medicine as instructed, as their medical history and any tests will already have been assessed.” Dr Branch adds that if a customer has any questions about their treatment, they should discuss this with their doctor at their next visit.

If customers are seeking an oral anti-inflammatory analgesic, they can still buy ibuprofen without a prescription. Sultan ‘Sid’ Dajani, independent community pharmacist and member of the Royal Pharmaceutical Society (RPS) English Pharmacy Board, says topical products (e.g. gels) containing diclofenac are also still available over-the-counter for muscle and joint pain. “It’s best if customers ask the pharmacist for advice to avoid contraindications though,” he says. “Customers should also seek advice from their GP on non-medical support and to check for any underlying condition.”

Q: Can I take paracetamol to ease my arthritis pain?

A: Paracetamol is considered a first-line treatment for mild to moderate osteoarthritis pain. It is recommended for long-term pain more often than NSAIDs such as ibuprofen as it is less likely to cause side effects (e.g. heart problems or stomach upsets). But research published in The Lancet in March revealed that paracetamol isn’t as effective for knee and hip osteoarthritis as previously thought. If customers rely on paracetamol for arthritis pain relief, they should speak to their GP.

According to Dr Maureen Baker, chair of the Royal College of GPs, it is best to err on the side of caution when taking the painkiller over a long period of time. “The majority of evidence still suggests that paracetamol is a safe drug for most patients,” she says. “But a number of recent studies do cast doubt on its effectiveness at treating osteoarthritis. Patients who regularly take paracetamol – either as prescribed by their doctor or self-medicated – shouldn’t panic as a result of this research. But if they are concerned about taking the drug regularly over a long period of time, they should make a non-urgent appointment with their GP, or discuss this with their local pharmacist.”

Q: How should I treat my lower back pain?

A: In March, the National Institute for Health and Care Excellence (NICE) issued draft guidance that downplayed the use of paracetamol on its own in lower back pain management. Instead, the guidance recommended exercise, such as stretching, yoga, strengthening and aerobic exercise, as a first-line treatment.

If customers need pain relief, they should use ibuprofen at the lowest effective dose for the shortest possible period of time. They should also be advised to try to continue with normal activities as far as possible to help them self-manage their pain.

Q: My baby is due to have the meningitis B vaccine. Why is my health visitor suggesting I give him a dose of paracetamol straight afterwards?

A: With most baby vaccinations, it’s not necessary to give paracetamol after the injection. But a fever is more likely to occur within the first 24 hours after the meningitis B vaccine, which is given to babies at two and four months. For this reason, doctors recommend giving a dose of infant paracetamol liquid soon after vaccination, rather than waiting for a fever to develop. Paracetamol will also reduce the chance of the baby being irritable or uncomfortable at the site of the infection.

Q: I have a mouth ulcer. What can I use to ease the pain?

A: Mouth ulcers are usually harmless, although painful, and may be triggered by biting the cheek or tongue, sharp teeth, overvigorous brushing or poorly fitting dentures. Stress, hormonal changes, smoking and certain foods are also thought to trigger recurring mouth ulcers. “All that is often needed is for a sharp tooth to be smoothed down or a denture adjusted,” says Karen Coates, dental advisor with the Oral Health Foundation's Dental Helpline. “A dentist can suggest a mouthwash, but a natural aid may be salt water – a teaspoon of salt in some cool boiled water. This may cause the ulcer to sting but can help with the inflammation. Topical treatments bought over-the-counter from a pharmacy will place a temporary barrier over the ulcer to minimise the discomfort.”

Q: What is the best OTC painkiller for period pain?

A: Period pain is usually felt in the lower abdomen or back. The cramps start shortly before or at the start of a period. The pain is caused by prostaglandins, which trigger muscular contractions in the uterus. The most effective painkillers are those that stop prostaglandin production – for example, NSAIDs such as ibuprofen and naproxen. If these fail to work, a GP can prescribe stronger medication. Applying a heat pad, relaxation techniques, a massage or some gentle exercise may help to relieve the pain too. Severe or persistent period pain, or period pain that starts for the first time in women in their 30s or 40s, should be investigated by a GP.

Q: I have migraine attacks every four months. Can I take OTC sumatriptan or should I go to my GP?

A: If customers ask for a migraine treatment, they should speak to the pharmacist, as it’s important to check that they’ve had a proper diagnosis. “If they are experiencing migraine every three to four months, there’s no reason why they can’t try OTC products,” says Dr Alok Tyagi, consultant neurologist at Southern General Hospital in Glasgow. “Some people find simple painkillers, such as paracetamol or ibuprofen, can relieve their migraine, so they should try these first. But as long as they’ve been diagnosed, have their usual symptoms and fit the criteria, they can take OTC sumatriptan. They should also try to identify their triggers, such as lack of sleep or missing meals, and avoid these if possible. If they experience nausea as well as a headache, they may benefit from an anti-emetic.”

Q: I work at a computer and often have a sore neck and a headache by the evening. What can I do?

A: Topical analgesics or heat pads on the neck and shoulders after work may ease the pain, and cooling forehead pads may ease the headache. But a more effective long-term solution would be to tackle problems with posture.

According to recent research from the British Chiropractic Association (BCA), almost one-fifth of those suffering from back and neck pain at work believe that using a computer triggers their pain. “Most people don’t realise that sitting and concentrating on the screen for so long could be harmful to their spine,” says BCA chiropractor Tim Hutchful. “Make sure the top of the screen is level with the eyebrows and the seat of the chair is tilted slightly forward, allowing for the knees to be lower than the hips and the feet to be flat on the floor. Don’t sit for more than 20 to 30 minutes at a time. Make sure you stand up to stretch, change position and walk around a little.”

The Alexander Technique is a system designed to promote wellbeing by improving awareness and habits of posture to ensure minimum effort and strain. Antonella Cavallone, Alexander Technique teacher, says people need to think themselves tall when sitting at a desk. “This will help them reorganise the alignment of their head, neck and back, will improve their postural support, reduce the compression in their torso and begin to eliminate the cause of the pain,” she says. “Thinking yourself tall will help you stop tensing your neck and craning the head forward. Your head weighs 4-5kg and that is a lot of weight to have pulling down from your neck.”

Q: I’m six months pregnant. How can I ease my back pain?

A: Back pain can be an issue for as many as 98 per cent of pregnant women. Paracetamol is the usual oral analgesic recommended by midwives and GPs for women who need pain relief in pregnancy, while topical products can offer drug-free pain relief and, as body temperature is usually higher during pregnancy, cooling products can bring welcome relief too.

Q: I often experience minor injuries when I play sports. When should I use hot and cold therapy products?

A: Cold therapy should be used as soon as possible after a new injury, such as a sprain or a strain. “Ideally, use cold therapy to minimise swelling,” says Stephen Makind, osteopath and founder of the Perfect Balance Clinic. “But apply it for 20 to 30 minutes maximum at one time, depending on the size of the painful area. Use a protective cloth between the skin and the ice pack, if using one. In the case of cold lotions and gels, most of them would probably wear off in that time period. Gentle movement is also recommended to prevent stiffness.”

Heat therapy shouldn’t be used until at least 72 hours after an injury. Topical warming products create rubefacient and counterirritant sensations on the skin, generating heat, which helps to increase the flow of blood, which brings oxygen, proteins and other nutrients to the area, all of which help to promote healing. Heat may be applied in the simple form of a hot water bottle or heat rubs, sprays and patches.

Q: Should I give my son a painkiller when he has a fever?

A: A high temperature is a sign that the body is fighting an infection and trying to heal itself. In November 2015, Professor Alastair Sutcliffe, professor of general paediatrics at University College London, said fever isn’t an illness and therefore doesn’t need to be treated with paracetamol unless a child is in pain (e.g. from an ear infection). Too much paracetamol, especially for several days, has been associated with an increased risk of developing asthma, as well as kidney, heart and liver damage. If a child has a fever, it’s essential that they’re kept hydrated with regular drinks of water or sugar-free water-based drinks.

According to NICE guidance, parents should give paracetamol or ibuprofen only if their child’s temperature is over 38°C and they are distressed or unwell. Paracetamol should be the first choice of painkiller, and ibuprofen used only if paracetamol isn’t effective. If neither painkiller is effective on its own, parents can alternate them. Paracetamol is usually given every four to six hours and ibuprofen every six to eight hours. Parents should keep a diary to avoid overuse, especially if more than one person is administering the medicines.

Different types of pain need different approaches, yet many people aren’t aware of this