A mixed-methods evaluation of a nurse-pharmacist–managed pain clinic: Design, rationale and limitations

Chronic pain affects 1 in 5 adults globally.1 A multidisciplinary approach is often required to effectively manage chronic pain. The limited capacity of general practitioners (GPs) and restricted access to pain clinics hinder effective management.2,3 Suboptimal prescribing of analgesics4 and inadequate monitoring of medicines5 are also well documented in this context. The recent English Pain Summit advocated that chronic pain should become a “high street disease, recognized and visible to all, with equitable access to treatment, care and education.”6 The increasing number of nurse and pharmacist prescribers presents an opportunity for professionals other than GPs to take on key aspects of pain management. Evidence to support the role of pharmacists and nurses in pain management is growing.7-10 However, the optimum configuration of such services ensuring maximum clinical and cost-effectiveness is not known. Rigorous evaluations of novel pain management approaches are essential for future health service provision. A community-based nurse-pharmacist–managed pain clinic was developed in Leeds, United Kingdom, in 2005 with the aim of effectively managing chronic pain within primary care and to reduce disease burden in secondary care. The working of the clinic has been explained in detail elsewhere.11 Briefly, when referred by a GP, patients are directed to the nurse-pharmacist–managed pain clinic or secondary care based on clinic guidelines. The nurse obtains a history of chronic pain, educates patients about pain, clarifies misconceptions and encourages self-management. The pharmacist obtains the medical and medication history and undertakes medication reviews with the aim of reducing adverse effects and drug interactions, as well as improving analgesia and adherence. Finally, the nurse and the pharmacist discuss and agree upon the treatment plan with the patient and the GP is informed about the suggested plan. Each consultation lasts for 60 minutes, and patients are usually discharged after 3 to 6 sessions. A feasibility study found a significant reduction in pain scores at discharge from the clinic (p < 0.001) together with reduced referrals to secondary care.12 Use of pain scores alone as an outcome measure, small sample size (n = 37) and lack of long-term follow-up data limits the findings of the study and warrants well-designed research to further strengthen the evidence.