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Australian Journal of Pharmacy : November 2006
chronic pain management In addition, radiotherapy can often pro- vide relief from the pain of bone metasta- sis and corticosteroids may be useful when pain is associated with oedema or inflam- mation.’ Pain and the elderly Dr Roger Goucke, director of pain man- agement at Sir Charles Gairdner Hospi- tal in Perth told the AJP that studies on the prevalence of chronic pain indicate about one in five Australians are affected. He said chronic pain was defined as pain lasting more than three months and the most common kind of pain is back pain. ‘Older people tend to have more pain than younger people, even though you can say there is one in five, or 20 per cent of people estimated to be suffering from chronic pain, not everybody is bothered by it, most people put up with it. So, there is not 20 per cent of the population trying to get into pain clinics.’ Dr Goucke said although chronic pain is more common in the elderly it is not How to fill the HMR gap? M AJP. Asked about what is not being done and what should be done in the HMR program, Dr Gowan said: ‘At the moment there is insufficient communication between the GP and the pharmacist, although the situation has improved. She suggested pharmacists could make action notes on the dispensing program. ‘Not enough HMRs are being done because the accreditation system is too costly and reimbursement is just not happening, and this is a very embarrassing situation for pharmacy. It was promised in March but has still not come through. ‘Another issue for pharmacy is finding the time to do HMRs and being motivated to do them. Pharmacists have not realised the benefits of increasing their HMR business by directly referring to the GP. Accreditation is costly in time and money. ‘Of course a lot of pharmacists simply won’t do them and they are losing patients as a result. What happens is the GP tells the patient to go to another pharmacist.’ Dr Gowan said there are legal issues to consider as a pharmacist could potentially be liable if the GP has ordered a HMR for a specific medication issue, for example, non-compliance, and no action had been taken. ‘This is something we have discussed with PDL [professional indemnity insurance body, Pharmaceutical Defence Limited].’ Dr Gowan said there were a lot of dedicated facilitators, working very hard in the community and collaborating with GPs in many areas such as making the hospital discharge system work more efficiently. Also, GPs encourage other GPs to become involved although a number of GPs think HMRs take up too much time and involve too much paperwork. Funding is also needed for interpreters. As Dr Gowan said, more than 50 languages are spoken in Australia and in order to meet this requirement and make HMRs efficient this problem had to be addressed. ‘We have a number of pharmacists who speak different languages who are happy to travel and undertake HMRs but, unfortunately, there are not enough of them.’ 44 ? THE AUSTRALIAN JOURNAL OF PHARMACY VOL.87 NOVEMBER 2006 because they are older but that they have more co-morbid problems. ‘You see more spinal degenerative dis- ease, more diabetic neuropathy or post- herpetic neuralgia, that are all commoner in older people.’ When it comes to treatment of chronic pain, Dr Goucke said the current thrust was to try and get people to understand the pain and look at self-management using community based self-management programs similar to those community education approaches used for cardiovas- cular disease. ORE than 107,000 HMRs have been conducted nationally since the Home Medicines Review program was established in July 2001. According to consultant pharmacist and HMR facilitator, Dr Jenny Gowan, HMRs are becoming core practice for some GPs but currently only 10–12 per cent of GPs are ordering the service. ‘Ultimately our aim is to have HMRs as routine patient care,’ she told the ‘For example, be an ideal weight, do regular exercise and that will decrease chronic pain. It all takes effort and many people don’t want the effort they would rather take medication. ‘The biggest complaint from pain peo- ple at the moment is that you cannot get gabapentin or pregabalin on PBS [Phar- maceutical Benefits Scheme]. ‘These two drugs are not available for pain management. Noone can persuade the government or the government phar- maceutical advisors to put them on the PBS even though there is a fair amount of good evidence and anecdotal evidence for their use. It is not strong enough to per- suade the PBAC [Pharmaceutical Benefits Advisory Committee]. These drugs are widely used around the world but it all comes down to federal and state cost shift- ing.’ And as for home visits by pharmacists for the elderly, Dr Goucke said they were very sensible as long as the pharmacists were on the same wavelength as pain doc- tors. ‘When we have pharmacists talking to our patients they are very pro-drugs whereas we tend to be anti-drugs. Many patients are taking NSAIDs when they don’t have inflammatory pain. If HMR pharmacists are properly educated to try and get people off their drugs that is a good thing.’ According to Dr Gowan, many patients are concerned about a drug-centric approach to pain relief. ‘When it comes to medications for pain relief we are discovering, particularly with