All pharmacists should be interested in pain and the focus of their practice should be on optimising medicines says Professor Knaggs.

Part of the work of the pain pharmacist is to identify ineffective pain treatment and help patients to develop self-management skills. The scale of opioid use disorder in the UK has not yet been quantified but “a sizable proportion of patients are certainly dependent upon their opioids”, he says.  Better education about opioids and careful patient monitoring when opioids are first prescribed could be the keys to reducing opioid-dependence and achieving effective pain management.

Professor Knaggs is the newly-elected President of the British Pain Society – an organisation that he has worked with for about 15 years. The organisation has members working in all areas of pain management including acute post-operative pain, chronic pain and palliative care.  During his presidency he hopes to see it develop more interaction with health care practitioners in primary care where the majority of patients are seen.

Patient care skills that have been honed in managing long-term conditions can be useful in the management of chronic pain, says Professor Knaggs. For pharmacists with an interest in pain, “One very good place to start …. is acute surgical pain and promoting rational use of medicines…”, he advises.

Roger Knaggs BSc BMedSci PhD EDPM FFRPS FRPharmS FFPMRCA, is Associate Professor in Clinical Pharmacy Practice, University of Nottingham and Specialist Pharmacist in pain management, Primary Integrated Community Solutions Ltd.

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There is only limited evidence at present relating to the impact of pharmacy-led pain services. Moreover, the available evidence comes largely from the USA rather than the UK or mainland Europe.  Like many specialist pharmacy roles, the pain specialist role has developed over time but has not yet been formally evaluated.  There is still room for research in this area, acknowledges Professor Knaggs

For pharmacists who think they might like to specialise in pain services, Professor Knaggs’ advice is “Go and explore – talk to people, perhaps in your local institution whether that be a hospital or a GP practice”.  One of the most rewarding features of working in pain is that much of the work calls for an holistic approach rather than an approach based on medicines alone, he says. “Whilst the focus may be medicines, you are needing to use other skills and expertise as well to maximize benefit and have the best outcomes for the individual.  I think that you can draw upon skills from managing other long-term conditions, particularly in terms of managing chronic pain”, he adds.

When it comes to getting started Professor Knaggs says, “One very good place to start …. is acute surgical pain and promoting rational use of medicines …..  If you’re working in hospital this may well be an area [to develop], particularly if you’re working as a surgical pharmacist and seeing patients in the early post-operative period and working closely with the acute pain service …… If you’re working in community or in in Primary Care having discussions with your colleagues may well be a way in which you can begin to develop an interest in seeing patients both with acute pain and chronic pain”.

Roger Knaggs BSc BMedSci PhD EDPM FFRPS FRPharmS FFPMRCA, is Associate Professor in Clinical Pharmacy Practice, University of Nottingham and Specialist Pharmacist in pain management, Primary Integrated Community Solutions Ltd.

Read and watch the full series on our website or on YouTube.

Professor Knaggs has been involved with the work of the British Pain Society (BPS) for approximately 15 years.  Originally a co-opted member of council, he was later an elected council member. He has served as honorary secretary and, most recently, as vice president.  “It has been a journey over many years and I think it would be fair to say that anything that has medicines involved will have had my involvement over the last few years”, he says.

During his presidency he would like to see the British Pain society looking at how it can interact with generalists in healthcare for whom “pain is a much lesser part of their job than people like me”, and particularly those in primary care “because actually that is where the majority of people with both acute pain and chronic pain are seen”, he explains.

The BPS has members whose main interests are more focused on acute pain following surgery as well as chronic pain and also palliative care and cancer pain. One important topic is ensuring that appropriate formulations are used. For example, some centres have used transdermal fentanyl patches for post-operative pain relief. Professor Knaggs says that neither transdermal fentanyl nor modified release oral preparations should be used for acute, post-operative pain.

Roger Knaggs BSc BMedSci PhD EDPM FFRPS FRPharmS FFPMRCA, is Associate Professor in Clinical Pharmacy Practice, University of Nottingham and Specialist Pharmacist in pain management, Primary Integrated Community Solutions Ltd.

Read and watch the full series on our website or on YouTube.

Professor Knaggs’ role in the clinic is to review patients who have been taking analgesic medicines for many years. “We look at the effectiveness of those medicines – in many cases patients will say that actually they are providing relatively little benefit …. A phrase that is very often used is “take the edge off” their symptoms, which really is a sign that they are not doing what both the patient and we as healthcare professionals would like”, he explains.  He then discusses with patients how the medicines are impacting their pain but also their life more generally.  This leads on to a discussion about other approaches to managing pain that they may wish to consider, such as improving their skills in self-management and more psychologically-based measures, rather than more medicines. Physical activity can also play a role here. “Activity can range from simple chair-based activity or a movement within one’s daily routine, but then it may extend to activities such as yoga. …. As individuals become more confident in their own abilities, maybe going to the gym to do light exercise or swimming…..It is really down to the individual as to what they’re going to feel most comfortable doing”, he says.

Opioid use disorder

“I think the first thing to say is that ‘opioid use disorder’ is a relatively new term that was introduced in the DSM-5 classification of illnesses and really describes problematic opioid use and that may be associated either with illicit substances or prescribed medicines and that it is associated with significant distress and impairment of activities”, he says  The majority of people that he sees in the clinic are taking prescribed medicines and it is relatively unusual for him to see people who are taking illicit opioids.  Nevertheless, a sizable proportion of patients are certainly dependent upon their opioids. However, whether they fit all of the diagnostic criteria for opioid use disorder is debatable, he explains. “It has not really been possible yet in the UK to quantify the scale of opioid use disorder related to prescription opioids”, he adds.

The main way to tackle opioid use disorder is to consider the initial prescription as an opioid trial. “If after a period of four to six weeks the opioid is not providing any benefit then that is the time to consider tapering and discontinuing rather than letting the prescription go on to repeat and patients then taking opioids for many months – and sometimes even years – without a great deal of benefit”, he says.

Initially, most of the evidence for opioid use disorder related to opioids for chronic pain. “However, there is a defined group of people [post-operative patients] who may be discharged from hospital with a supply of opioids and in many cases these patients were not actually taking opioids prior to that procedure so they are a very discrete group of individuals”, he says. A careful explanation when the opioids are first prescribed and then regular review thereafter are important measures, he adds.

Roger Knaggs BSc BMedSci PhD EDPM FFRPS FRPharmS FFPMRCA, is Associate Professor in Clinical Pharmacy Practice, University of Nottingham and Specialist Pharmacist in pain management, Primary Integrated Community Solutions Ltd.

Read and watch the full series on our website or on YouTube.

Professor Knaggs is an academic pharmacist who combines teaching and research in the School of Pharmacy at the University of Nottingham with hands-on clinical work in a community-based pain service, one day a week.  His interest in pain started when he first came to Nottingham as a PhD student. His research was related to morphine metabolism and pharmacokinetics. “Then, rather serendipitously, I moved into a specialist pharmacist role at what was then Queen’s Medical Centre (and is now part of Nottingham University Hospitals NHS trust) and I was the specialist pharmacist for anaesthetics and pain”, he recalls. Initially the work was mainly in acute pain but over a period of years he became more involved in chronic pain. “After several years of doing clinics together with some of our nursing colleagues, I started to develop my own clinics to look at optimising medicines for pain”, he says.

There are several reasons why all pharmacists should be interested in pain, he says. “First of all, it is such a common experience – so every pharmacist is going to see people who may experience pain and it is associated with many different diseases and illnesses.  In terms of chronic pain, the reason why pharmacists should be interested is there has been in increasing amount of evidence to actually say that medicines only work for a relatively small proportion of people. And so, perhaps the emphasis should be now much more around optimising medicines and people only continuing to take them over longer periods of time if they actually make some significant difference to reducing their pain and allowing them … to do more”, he explains.

Roger Knaggs BSc BMedSci PhD EDPM FFRPS FRPharmS FFPMRCA, is Associate Professor in Clinical Pharmacy Practice, University of Nottingham and Specialist Pharmacist in pain management, Primary Integrated Community Solutions Ltd.

Read and watch the full series on our website or on YouTube.