MCA Training Made Easy

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1 MCA Training Made Easy MODULE 2 Pain Learning objectives After reading this module you will: Understand why managing pain is important in the pharmacy Be aware of what causes pain Understand the medicines available to treat pain Know that there are important safety issues related to pain relief medicines Recognise a variety of painful conditions and how to treat these Recognise when customers need to be referred to the Be able to offer added pharmacy value to the customer seeking pain relief 1 Prostaglandins play an important role in causing pain, swelling and inflammation of damaged tissues Pain is divided into two types: acute (short-term, sharp pain) and chronic (long-term, dull pain). Pain can be mild, moderate or severe The Track and Train Medicines Counter Assistant Course is accredited by the General Pharmaceutical Council as providing the essential knowledge required to work in a pharmacy as a Medicines Counter Assistant. ALWAYS REMEMBER WWHAM! When recommending a suitable medicine for a customer, always remember the WWHAM questions to help you get the right information for your decision: Who is the medicine for? What are the symptoms? How long have the symptoms been present? Has any Action been taken so far? Are any other Medicines being taken? PART 1: PAIN Why is pain important? Pain is the most common reason customers come into the pharmacy. It s why the pharmacy shelves are bulging with products. This module aims to make it easier for you to recommend the right pain reliever (also known as an analgesic) for each customer s needs. What is pain? You may not know it, but pain is actually a good thing. It s a warning system that the body has put in place to protect us. For example, if you accidentally put your hand on a hot stove, the pain that this causes is your body s way of telling your brain to get your hand off that stove. Pain itself is not a condition, it is a symptom of many conditions. It s a very personal experience, some people seem to be able to cope with a great deal of pain while others crumble at the least little bump. How do we feel pain? Pain is the result of a complex series of messages passed along nerves from the site of injury to the brain, which registers we are hurting. When we have hurt ourselves, the pain is picked up by special sense receptors in the skin, bones, joints and muscles. These receptors pass the pain signal along the nerves until they reach the spinal cord, which then releases more chemical transmitters to transfer the pain signal to the brain. What is the role of prostaglandins? Prostaglandins are chemicals released by our body tissues when they are damaged. They cause pain, swelling and inflammation. What are the different types of pain? Pain can be divided into two types: acute and chronic: Acute pain lasts for a short time and can be described as sharp, stabbing, thumping and pounding. Chronic pain is a long-term pain that is there for most days, though some days may be better than others. Customers will describe chronic pain as dull, throbbing and deep. How bad can pain get? Pain can be mild, moderate or severe. Fortunately, most pain seen in the pharmacy is mild-to-moderate. Any customer who is in severe pain should always be referred to the. PART 2: PAIN RELIEVERS What do we treat pain with? Pain is treated with pain relievers also known as analgesics. Pain relievers are available in different forms: oral: tablets, capsules, soluble, effervescent, liquids topical: creams, gels, rubs, sprays, patches, roll-ons suppositories: these are bullet-shaped pellets that are inserted into the back passage. Over the counter (OTC) pain relievers can treat mild-to-moderate pain. Oral and suppository forms can also reduce high temperatures.

2 Time Out Over the course of several days, make a note of every customer that asks for a pain reliever. How did they describe their pain, how severe was their pain, and what painful condition did they need your advice on? This not only helps you recognise how often you deal with pain in the pharmacy but also shows the many different conditions you need to become an expert on. It can also help prompt you to re-evaluate the treatments you keep in stock and perhaps consider ways to improve the way they are merchandised. 2 Added ingredients such as caffeine and codeine improve the efficacy of analgesics. Other ingredients, such as antihistamines and decongestants treat additional symptoms associated with pain What pain relievers are available? Oral: There are four main oral analgesics available, all of which start relieving pain in around minutes after taking them: Aspirin (e.g. Anadin) a non-steroidal anti-inflammatory drug (NSAID), which reduces pain, fever and (in prescription doses) inflammation (swelling and redness). It s important to remember that aspirin cannot be sold for children under the age of 16 years because the risk of Reye s syndrome (a rare condition in children which causes brain swelling and can be fatal) Ibuprofen (e.g. Nurofen) an NSAID which reduces pain, fever and (in prescription doses) inflammation Paracetamol (e.g. Panadol) an analgesic that acts in the brain to reduce pain and fever. It has no effect on inflammation Another NSAID pain reliever called naproxen is also available OTC for the treatment of period pain only. For more information see Understanding Period Pain later in this module. Topical: In addition, the following ingredients are present in topical pain relievers: Rubefacients these include methyl salicylate, camphor and menthol. They cause skin irritation producing a feeling of warmth (except for menthol which produces a sensation of coolness) over the area where they are applied, which helps to mask pain NSAIDs reduce pain and inflammation. e.g. ibuprofen (e.g. Ibuleve gel), diclofenac (e.g. Voltoral Pain-eze Emulgel) Others such as benzydamine salicylamide and local anaesthetics Suppositories: Most analgesic suppositories are available only on prescription, but you may come across paracetamol suppositories (e.g. Alvedon) which can be sold only from pharmacies. Added ingredients There are a number of other ingredients that can be added to some of the main analgesics, including: Antihistamines (e.g. diphenhydramine) used to treat blocked up noses. Older antihistamines can cause drowsiness and should not be taken by anyone who needs to drive. They should also not be taken with alcohol as they can increase the likelihood of drowsiness. Some cannot be taken by children so always check the label to see what age it is suitable for. Buclizine used to treat sickness and nausea and present in some anti-migraine products. It is an antihistamine so can cause drowsiness and should not be taken with alcohol. Again, look at the label to check what age it can be used from. Caffeine this is claimed to increase the speed of action of aspirin and paracetamol. Although the amount present in analgesic products is similar to the amount of caffeine in a strong cup of coffee, people can get addicted (in the same way they do to coffee!) and if too much is taken it can actually cause headaches. Codeine and dihydrocodeine these are strong analgesics used in small doses in OTC products to give additional pain relief. They can cause nausea, vomiting, drowsiness and constipation and people taking them regularly can become addicted. Because of the risks of addiction, the number of tablets containing codeine or dihydrocodeine that are available in packs is limited to 32. Products containing these medicines are also restricted to use for the short term treatment of acute, moderate pain that is not relieved by paracetamol, aspirin or ibuprofen alone, and for no longer than three days. They cannot be taken by children under 12 years of age. Decongestants, such as pseudoephedrine or phenylephrine are used to treat the blocked nose symptoms of cold and flu that can cause pain around the eyes and forehead. Oral decongestants should not be used in people with high blood pressure, who have heart problems or who are taking certain anti-depressant medicines. Guidance has been produced on the safe supply of pseudoephedrine (see Winter Health Module 6). Doxylamine an antihistamine used to relieve muscular tension. Like other antihistamines it can cause drowsiness. Isometheptene used in anti-migraine treatments, it should not be taken by people using certain anti-depressant medicines. How analgesics work Non-steroidal anti-inflammatory drugs (NSAIDs) act by blocking the production of prostaglandins, which cause pain and inflammation at the site of pain. Aspirin and ibuprofen reduce pain at OTC doses, but there is no evidence that they have an effect on inflammation at these lower OTC doses. Diclofenac and naproxen reduce pain and inflammation at their OTC doses. However, prostaglandins are also present all over the body, including the stomach and kidney. So by blocking prostaglandins that cause pain,

3 MODULE 2 Pain management NSAIDs also block those that are in other parts of the body, and this can lead to side effects. Paracetamol is not an NSAID (has no effect on inflammation) and it is thought that it works only in the brain, which may be why it has few side effects when used at normal doses. Understanding paracetamol Paracetamol can be used by just about everybody, though refer to the if the customer has kidney or liver problems or is a chronic alcoholic. It can be taken by children from three months (two months with doctor s advice), and when recommended by a doctor it can be taken by pregnant women. It rarely has side effects and can be used by people taking most medicines. However, paracetamol can be extremely dangerous when too much is taken (called an overdose). This can cause liver damage, liver failure and death. Always advise customers to stick within the recommended doses (one to two 500mg tablets every 4-6 hours, up to a maximum of 8 tablets in 24 hours for adults and children over 12) and not to take any other medicines containing paracetamol. This can be easily done accidentally if someone is taking paracetamol to relieve a headache and then also takes a paracetamol-containing cold and flu remedy. Children s doses vary according to age but should be no more than four doses in 24 hours. The doses for children are as follows: 3-6 months, 60mg; 6 months-2 years, 120mg; 2-4 years, 180mg; 4-6 years, 240mg; 6-8 years, 240mg; 8-10 years, 360mg; years, 480mg. For more information see Children s Health Module 5. Because of the risks of overdose there is a limit to the number of paracetamol tablets that are available in packs: 16 tablets/capsules in a GSL pack; 32 tablets in Pharmacy packs. Customers who request larger quantities should be referred to the. Understanding NSAIDs NSAIDs such as aspirin and ibuprofen are good for painful conditions that are accompanied by swelling and inflammation such as sprains. However, because they affect prostaglandins all over the body, they can cause a number of side effects. These include stomach problems (indigestion, heartburn, stomach ulcers and bleeding), asthma attacks in asthmatics sensitive to aspirin, ringing in the ears and an increase in the time it takes the blood to clot. Therefore, they cannot be taken by people who have or have had a stomach ulcer, or people who have had an asthma attack after taking NSAIDs. Aspirin and ibuprofen should always be taken with or after food as this helps reduce stomach irritation. Considerations for aspirin: When recommending aspirin for adults and children over 16, the pain relieving dose is mg every 4-6 hours, up to a maximum of 12 x 300mg tablets every 24 hours. As well as tablets and capsules, it is available as 300mg soluble and enteric coated (EC) formats. The coated format is better for people who have a stomach that is sensitive to aspirin. Aspirin can also be sold as a dispersible 75mg dose to be taken with water after food for people with heart disease, following a doctor s advice. Aspirin cannot be used in children under the age of 16 years because of the risk of Reye s syndrome (leads to brain swelling and liver inflammation that can be fatal). Some people are allergic to aspirin and the drug can react with certain medications that a person may be taking. The amount of aspirin tablets that can be sold for pain relief is restricted, like paracetamol. GSL packs contain 16 tablets/capsules and Pharmacy packs contain 32 tablets/capsules. Customers who request larger amounts should be referred to the. However, these restrictions do not apply to 75 mg aspirin so you can sell 100 tablet packs as a normal Pharmacy pack. Considerations for ibuprofen: For ibuprofen, the maximum adult dose is 1.2g per day (400mg every 6-8 hours). Children s doses vary according to age, and it can be used from the age of three months. The doses for children are: 3-6 months (body-weight over 5 kg) 50 mg 3 times daily; 6 months-1 year 50 mg 3 4 times daily; 1-3 years 100 mg 3 times daily; 4-6 years 150 mg 3 times daily; 7-9 years 200 mg 3 times daily; and years 300 mg 3 times daily. For more information see Children s Health Module 5. Time Out Make a list of the pain relieving products on your shelves and create a table outlining: brand name, main analgesic ingredient(s). This helps you to recognise that many products which have similar names may contain different ingredients. Paracetamol works differently to NSAIDs and doesn t cause many side effects when taken at recommended doses Paracetamol can cause liver damage and death when taken in overdose so always advise customers to stick to the recommended dose Aspirin and ibuprofen are NSAIDs and reduce pain and fever and, in high, prescription doses, also reduce inflammation. 3

4 Time Out Make a list of the most common side effects customers may experience after taking aspirin, paracetamol and ibuprofen. Referral The following customers who ask for any NSAID should be referred to the : those with asthma; high blood pressure; diabetes; heart, liver or kidney disease; the elderly; pregnant or breastfeeding women; and anyone on any other medication. People taking a prescription drug called methotrexate especially need to avoid taking NSAIDs and must be referred to the. People asking to buy aspirin for children under 16 must also be referred to the. Topical NSAIDs Topical NSAIDs, such as ibuprofen and diclofenac, generally avoid the side effects and drug interactions seen with oral formulations.. Topical and oral NSAIDs should not be used at the same time SUMMARY TABLE: PAIN RELIEVERS AT A GLANCE Aspirin Ibuprofen Paracetamol Child aged under 3 months (after vaccination) Child aged 3 months-16 years Elderly customer Has/has had stomach ulcer Has asthma Caution* Caution* Has allergic disease NSAIDs act on pain and fever by blocking prostaglandin production. They also act on other prostaglandins in the body causing side effects Has high blood pressure/is taking high blood pressure medicines Has blood problems Has heart problems Has kidney problems Has liver problems Is a chronic alcoholic Is pregnant Is breast feeding Is taking other medicines *Check if they have had an asthma attack after taking aspirin or another NSAID. If they have then they must avoid aspirin and all other NSAIDs in the future. 4

5 MODULE 2 Pain management PART 3: COMMON PAIN CONDITIONS Understanding headache What is headache? Headaches are the most common type of pain seen in the pharmacy. Some 96% of people will have a headache at some time in their lives. There are several different types of headache. Tension headaches: is the most frequently seen headache and is also known as stress headache. They are usually caused by stress or bad posture and customers will have a constant ache all over the head, possible tightness in the neck and shoulder and a pressure behind the eyes. These headaches usually last for just a few hours. Cluster headaches: these happen rarely. A cluster headache comes with severe pain which tends to affect just one side of the head for short periods. Unlike tension headaches, they occur frequently for several weeks. The cause is not known. Hangover headaches: this is the morning after the night before headache and is caused by dehydration and swelling of the blood vessels as a result of excess alcohol. Managing headache Tension headaches: can be managed with a pain reliever. However some people may have tension headaches that last for several days and they should be referred to the. Cluster headaches: pain relievers don t work for cluster headaches and any sufferer should be referred to the. Hangover headaches: any pain reliever can help, though if the customer is not up to eating, paracetamol is a good choice as, unlike NSAIDs, it can be taken on an empty stomach. There are a number of products aimed at people with hangovers that also help settle a disturbed stomach. Understanding migraine What is migraine? Many people confuse a bad tension headache with migraine, but the symptoms are quite different. In migraine the pain will usually only be on one side of the head and there are other symptoms, such as a dislike of bright light, nausea, vomiting and being unable to bear noise. Some people experience a visual or other disturbance (called an aura) before an attack, but this doesn t always happen. While it s not known what exactly causes migraine, it is believed to be due to the blood vessels in the brain becoming wider. This may be the result of a drop in the brain chemical serotonin. Most people with migraine will develop an attack in response to triggers, which include certain foods (for example cheese, chocolate, alcohol, caffeine, citrus fruits), missing meals, stress or anxiety, bright lights, changes in the weather, tiredness and hormones (in particular, around a period or if on the contraceptive pill). A migraine attack can last anything from between 4 hours to several days and can really leave sufferers unable to do the simplest of tasks. Managing migraine Until recently, migraine could only be treated with products that treated the symptoms of migraine, such as pain relievers for the pain and anti-sickness ingredients, like buclizine. However, now there is a specific OTC treatment for migraine that acts directly on the root cause of the problem. Sumatriptan (Imigran Recovery) belongs to a class of drugs called the triptans which are the leading prescription medicines for migraine. It relieves not just migraine headache, but also nausea and sensitivity to light and sound. Around half of users can be free from pain two hours after taking a sumatriptan tablet. If a customer asks for sumatriptan refer them to the. Before the can recommend sumatriptan, customers should be asked to complete a questionnaire which helps determine whether they are suffering from migraine and whether sumatriptan is right for them. The Royal Pharmaceutical Society has produced guidance on this (available from their website). Tips when recommending sumatriptan The dose is a single 50 mg tablet taken as soon as possible after the migraine headache starts in people aged years A second tablet can be taken if symptoms return, but no sooner than two hours after the first tablet has been taken. However, if there is no improvement after the first tablet, then a second dose will not work either The maximum dose is 2 tablets (100 mg) in 24 hours The most common side effect is an intense feeling of tingling, warmth, heaviness and pressure in the chest, throat and other parts of the body. Although this is a sign that sumatriptan is working, if this effect lasts longer then two hours the customer should see the or doctor People with the following conditions should be referred to the before recommending sumatriptan: heart disease/high blood pressure or who have risk factors for heart disease, history of stroke, poor blood flow to the legs, liver or kidney disease, epilepsy, pregnant or breast feeding women or those taking other medicines Cluster headaches are rare. Signs include severe, intense pain on one side of the head that lasts for no more than a couple of hours Migraine is a moderate-to-severe headache that affects only one side of the head. Other symptoms include nausea and dislike of light or noise 5

6 NSAIDs are the pain relievers of choice for period pain as they act directly on prostaglandins in the womb Headache: WHEN TO REFER TO THE PHARMACIST Anyone with a severe headache that has come on suddenly If it seems to be a cluster headache If there is also fever and blurred/double vision, weakness in the arms and legs, drowsiness, confusion, skin rash, seizures or tinnitus (ringing in the ears) A severe headache that lasts longer than 24 hours The headache doesn t improve after taking analgesics or is still present after several days The headache happens after a recent head injury A child with headache Customers with 4 or more migraine attacks per month Customer who has their first migraine attack after the age of 50 Women who are on the contraceptive pill who have started suffering from migraine within the past three months can be used to treat period pain but naproxen (e.g. Feminax Ultra) is an OTC product specifically for period pain. Considerations for naproxen: naproxen can be used by females between 15 and 50 years old for a maximum of 3 days during any period. On the first day 500mg (2 is taken to start with,then 250mg (1 tablet) can be taken after 6 to 8 hours if needed. If needed on the 2nd or 3rd day one tablet can be taken every 6-8 hours. The maximum number of tablets that can be taken in 24 hours is 3. Naproxen is an NSAID so you should look back at the section Understanding NSAIDs for information on when to refer customers asking for naproxen to the. Period pain: WHEN TO REFER TO THE PHARMACIST If symptoms have recently changed, e.g. the pain lasts longer or is more severe If there is also pain at other times of the month If bleeding is heavy If there is bleeding between periods 6 Sprains and strains are the most common sports injuries Period pain causes cramping of the lower abdomen, lower back and thighs TOP TIPS Your extra help in headache and migraine You can also offer management tips for headache and migraine sufferers: Tension headache sufferers: relaxation techniques, such as yoga, can ease stress; massages can alleviate neck pain and tension Migraine sufferers: offer advice on preventing future attacks such as identifying their migraine triggers, taking regular exercise, eating healthily and regularly, keeping a regular sleep pattern and managing stress (if stress is a trigger). Understanding period pain What is period pain? Period pain affects 40-70% of women of childbearing age. It is a low abdominal cramping pain, which can spread to the lower back and thighs, which happens before and during a period. Period pain is believed to be caused by the pain-inducing chemicals prostaglandins, which help the womb contract and shed its lining during periods. Managing period pain NSAIDs which help stop prostaglandin production should be the first choice recommendation for customers. All OTC NSAIDs Understanding toothache What is toothache? Toothache is usually caused by a problem with the tooth, most often tooth decay. But it can also be due to receding or infected gums and damaged teeth (for example, when a filling needs repairing or if the tooth is fractured). Having inflamed sinuses also causes pain in the upper teeth so check that customers do not also have a blocked nose. Managing toothache Anyone who has toothache should be advised to see their dentist as soon as possible, but in the meantime pain relievers can help. In theory, NSAIDs should be the most effective analgesics for toothache, but many people may wish to use combination ingredients for extra analgesic effect for severe pain. Understanding sports injuries What are sports injuries? Most sports injuries are caused by accidents (failing to use equipment properly, or being at the receiving end of a nasty tackle) or overuse of the muscles in competitive athletes. Sprains are common sports injuries, with symptoms such as pain, swelling, bruising and some stiffness on movement of the affected area. They are caused by a stretching or tear of the ligament. Tendonitis is due to overuse, tear or strain of the tendon and also results in pain, swelling and stiffness. The affected area may also look red.

7 MODULE 2 Pain management Managing sports injuries Advise customers to use the RICE treatment: Rest the area for 2 days (to reduce swelling and injury) Ice pack applied for minutes (to reduce pain and inflammation) Compression (from bandages) and Elevation (to reduce water retention in the affected area) Pain relievers can be taken, either oral or topical forms (gels, sprays, rubs containing NSAIDs), depending on customer preference. OTC pain relievers (e.g. paracetamol or ibuprofen) should be used for sprains and strains. In addition, you can also recommend topical pain relievers (e.g. diclofenac). TOP TIPS Your extra help in sports injuries You can also offer management tips for sports injuries: Don t do any more exercise until the injury has healed Preventative measures, such as warm up and cool down periods before and after exercise, can help strengthen muscles Support bandages can be useful in some cases. Sports injuries: WHEN TO REFER TO THE PHARMACIST If the RICE treatment has been followed and pain and swelling have not improved after a few days The injured joint is very swollen soon after being damaged The customer cannot move the affected area or put any pressure on it The pain is severe, e.g. a dislocation You suspect there could be a fracture If there is a head injury Managing backache It used to be thought that bed rest was the best thing for back pain, but that s no longer the case. Hard as it might sound for customers, keeping mobile is the fastest way to recover. A suitable OTC analgesic, which should be taken regularly to help keep pain at bay, rather than taken just when needed. Customers may find topical pain relievers are also helpful - massaging them into the back can feel very therapeutic and relaxing. TOP TIPS Your extra help in back pain You can also offer management tips for back pain sufferers: Avoid bed rest and keep moving Avoid lifting and carrying where possible Always lift with the knees bent For chronic backache, strengthening exercises, such as swimming, walking and Pilates can help Yoga can improve posture and ease pain Backache: WHEN TO REFER TO THE PHARMACIST The backache has not improved after 10 days The pain has moved to the legs, arm or groin The pain gets worse on coughing, sneezing or straining There is numbness or tingling in the limbs or feet, and toes cannot move properly There is temperature and/or fever or nausea and the pain is mainly on one side of the small of the back (this could be a kidney infection) To prevent future sports injuries encourage customers to do warm-up and cool down exercises Recommend the RICE technique for sports injuries. Paracetamol is recommended by guidelines as the first choice analgesic Understanding backache What is backache? Back pain is the single biggest muscle problem in the UK. Around 8 out of ten of us will have backache at some point in our lives. For most people the back pain is acute a short flare-up that lasts from a few days to a few weeks. Low back pain: also known as lumbago, it is by far the most common back pain. The pain can also spread to the buttocks, the back of the thigh or groin. Sciatica: this is a pain that runs along the length of the sciatic nerve, which travels down the buttocks, the back of the leg to below the knee. It is caused by pinching or trapping of the sciatic nerve. Understanding fibromyalgia What is fibromyalgia? Fibrositis is now more usually called fibromyalgia and is a chronic pain condition of the muscles. It does not affect the joints and should be diagnosed by the doctor as it can be difficult to identify. Any part of the body can be affected and there will also be extreme tiredness. The causes of fibromyalgia are unclear however it is likely that there are several possible triggers. Managing fibromyalgia Oral or topical pain relievers can help but in chronic cases, where pain can be severe, customers may need prescription medication. Back pain is one of the biggest problems you ll face in the pharmacy 7

8 8 Time Out Which analgesic or action would you recommend for each of the following customers and what extra help can you provide? Elderly man with a bad knee, not taking any other medicines Woman who regularly gets migraines around her period, with no other medical problems Man with hangover headache who also feels queasy. Teenager, aged 15, who has a sprained ankle following a football game Woman with period pain which is worse than normal Middle aged man with back pain after gardening. Not taking other medicines Osteoarthritis is the most common type of arthritis Lifestyle management is the first step in managing osteoarthritis TOP TIPS Your extra help in fibromyalgia You can also offer management tips for fibromyalgia sufferers: Exercise can help reduce pain, in particular stretching and yoga Avoid too much alcohol and caffeine as these can be triggers in some people Some sufferers have found alternative remedies, such as chiropractic, acupuncture and osteopathy can help. Understanding neuralgia What is neuralgia? Neuralgia is a local pain coming from one of the sensory nerves which transmits sensations to the brain. If this nerve becomes damaged, either by injury or following an infection, quite severe pain can occur. Managing neuralgia These are usually one-off incidents and can be managed by pain relievers. If these don t work the customer should be referred to their GP. Understanding mild arthritis What is mild arthritis? Arthritis is not just one condition but covers over 200 different ailments of muscles and bones. The most common complaint is mild arthritis, better known as osteoarthritis (OA). This is caused by wear and tear of the joints as we get older. The symptoms are pain and stiffness in the joints, often with reduced mobility. Managing mild arthritis 1. Non-drug options such as physiotherapy, strengthening exercises for the affected joints, losing weight if needed and using mobility aids to help with difficult tasks 2. If these don t work, paracetamol should be the first pain reliever recommended to customers with mild arthritis pain. This is not just because it is effective, but it also causes fewer side effects in older people than NSAIDs, like ibuprofen and aspirin 3. If necessary, a topical NSAID analgesic, like ibuprofen or diclofenac can be added 4. If more relief is required then an oral NSAID can be taken TOP TIPS Your extra help in osteoarthritis You can offer lifestyle changes for OA. These should be tried before and alongside any pain relief recommendations: Try physiotherapy to improve joint mobility and strength Do aerobic exercises to help strengthen the joint Lose weight as excess weight can put additional pressure on the joints, especially the knees Use mobility aids to help make life easier, such as thick pens, tap turners, walking canes Wear suitable footwear, such as trainers, that support the foot. Arthritis: WHEN TO REFER TO THE PHARMACIST If all of the above measures have been tried but the pain has not been relieved If other medicines are being taken many sufferers are elderly and have other health problems If it is the first time there is pain or stiffness in the joints If there are other symptoms, such as tiredness, loss of weight or appetite, bowel problems or skin conditions Numbness or tingling in the limbs or cannot move feet and toes properly Understanding colds and flu We ve all know what it s like to have colds and flu the runny nose, the sneezing, sore throat and, most painful of all, the aching joints. They are caused by viruses there are over 200 cold viruses alone! There s not much we can do to shorten the duration of a cold, but we can recommend customers take pain relievers to ease the discomfort. When recommending pain relievers, always ask customers if they would like just a pain reliever or if they would prefer it combined with other ingredients such as decongestants to tackle runny noses, too. And remind them not to take a paracetamol pain reliever with a paracetamol-containing cold and flu remedy because of the risk of overdose. More information on colds and flu and how to manage them will be included in a later module (see Winter Health Module 6). Understanding pain in children Managing children s health is covered in more detail in a later module (see Children s Health Module 5), but questions about managing children s pain and fever are common in the pharmacy. As a general guide, paracetamol and ibuprofen are suitable for use in children (from 2 months on doctor s guidance for paracetamol and from three months from the pharmacy). Aspirin should never be recommended for use in children under 16 because of its links to Reye s syndrome.

9 AT A GLANCE: MEDICINES USED IN THIS MODULE Drug Main Actions Main Side Effects Asprin (e.g. Aspro Clear Buclizine (e.g. Migraleve Pink Caffeine (e.g. Panadol Extra Codeine (e.g. Co-codamol Diclofenac (e.g. Voltarol Pain-eze Emulgel) Dihydrocodeine (e.g. Paramol Diphenhydramine (e.g. Propain Caplets) Doxylamine (e.g. Propain Plus Caplets) Ibuprofen (e.g. Nurofen Naproxen (e.g. Feminax Ultra Paracetamol (e.g. Panadol Phenylephrine (e.g. Beechams Decongestant Plus) Pseudoephedrine (e.g. Sudafed Non-Drowsy Decongestant Non-steroidal anti-inflammatory drug (NSAID), which reduces pain, fever and (in prescription doses) inflammation (swelling and redness) Antihistamine used to treat sickness and nausea Stimulant Opiate NSAID which relieves pain, and inflammation at OTC doses Opiate Antihistamine unblocks nose, cough suppressant action Antihistamine used to relieve muscular tension NSAID which reduces pain, fever and (in prescription doses) inflammation NSAID which reduces pain, fever and (in prescription doses) inflammation Analgesic Decongestants Decongestants Generally mild and infrequent but high incidence of gastro-intestinal irritation Drowsiness headache, impaired co-ordination, difficulty in passing urine, dry mouth, blurred vision, and gastro-intestinal disturbances May cause headaches Nausea and vomiting (particularly in initial stages), constipation, dry mouth Skin irritation. Nausea and vomiting (particularly in initial stages), constipation, dry mouth Drowsiness, headache, impaired co-ordination, difficulty in passing urine, dry mouth, blurred vision, and gastro-intestinal disturbances Drowsiness, headache, impaired co-ordination, difficulty in passing urine, dry mouth, blurred vision, and gastro-intestinal disturbances Gastro-intestinal discomfort, nausea, diarrhoea, and occasionally bleeding and ulceration Gastro-intestinal discomfort, nausea, diarrhoea, and occasionally bleeding and ulceration Rare, but includes rashes, blood disorders Increased blood pressure, headache Rapid heartbeat, anxiety, restlessness, insomnia 9

10 AT A GLANCE: MEDICINES USED IN THIS MODULE Drug Main Actions Main Side Effects Phenylephrine (e.g. Beechams Decongestant Plus) Pseudoephedrine (e.g. Sudafed Non-Drowsy Decongestant Decongestants Decongestants Increased blood pressure, headache Rapid heartbeat, anxiety, restlessness, insomnia Complete your learning Well done on completing the module! Now visit to access: Weblinks to learn more and signpost your customers Forum to chat with other MCAs about your learning Online assessment to make sure you are on track