Knowledge of each patient's unique needs can help in selecting the most appropriate drug.
Knowledge of each patient’s unique needs can help in selecting the most appropriate drug.
By now, pharmacists should fully understand pain basics: pain starts with nociceptive stimulation and progresses to signal transmission and central decoding, and then the brain registers “ouch!” Every patient’s pain is a unique, unpleasant sensory and emotional experience. The cliché, “I share your pain,” is scientifically implausible for physical pain; no one knows what the patient feels except the patient. Some pain requires multidisciplinary approaches with well-orchestrated interventions. Almost everyone experiences mundane, annoying, easily treatable pain.1 Pharmacists can help patients who are overwhelmed by the OTC analgesic aisle.
Two types of pain are extremely common: headache and musculoskeletal pain. Headache (tension, migraine, and sinus) accounts for about one-half of reported pain and one-third of all OTC analgesic doses.2,3 Musculoskeletal pain is often injury related but can be idiopathic. As patients age, osteoarthritis is a common cause. Women commonly experience menstrual pain. An extensive physical exam, a hard physical therapy session, or a biopsy can cause iatrogenic pain.4-6
When pain creates discomfort, patients can choose from among several oral analgesics (acetaminophen, aspirin, or nonsteroidal anti-inflammatory drugs (naproxen, ketoprofen, and ibuprofen]) as single-entity products or combination products. The plethora of products can confuse patients. Further exacerbating their confusion, one-fourth to one-half of patients do not read product labels.7,8 Perhaps patients believe they know the product or do not realize that from time to time, manufacturers lower the maximum daily dose or change the directions. Some people believe they can dose themselves regardless of label recommendations.7 By ignoring labels, patients may unintentionally exceed the maximum recommended dose or unknowingly purchase a combination product. The more than 380 acetaminophen-containing products are of special concern.7 In recent years, the FDA changed labeling to warn heavy alcohol users about acetaminophen and also decreased the maximum daily dose for 500-mg, OTC, single-ingredient acetaminophen products from 4 g/day to 3 g/day.9-11
Our primary goal is to reduce pain intensity and duration, restore normal function, and avoid side effects. Additionally, avoiding drug interactions is important for patients who take long-term prescription (or nonprescription) medication. Table 1 describes background information needed to make informed choices about OTC analgesia.
If headache is the problem, patients may find that relaxation exercises, better hydration, and sleep help. Avoiding triggers can also help. Migraine headache may not respond to OTC analgesics if the headache is fully developed.12 For sinus headache, a decongestant—analgesic combination product may be warranted.
For musculoskeletal conditions, experts recommend PRICE (protection, rest, ice, compression, elevation; online Table 2), although little research supports this intervention.17 Note that ice can relieve soreness, but it reduces muscle strength and power, negatively affecting performance. This means athletes who plan to return to the game immediately should avoid ice.18
Table 2. PRICE for Musculoskeletal Pain
Adapted from references 17-19.
Pharmacists must consider each patient’s unique needs and help patients select the drug, as well as route and mode of administration, that best meets their needs. For some patients (eg, those who have trouble swallowing), a liquid or rectal formulation will be needed. Others may find a counterirritant patch or cream containing menthol or methyl salicylate helpful. Pharmacists should educate patients to take analgesics appropriately, know when they have successfully self-treated, and seek more help if the quality of the pain changes.
Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance clinical writer.