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Nate Hentschel – Pain

Acute Pain in Community Pharmacy
To manage pain in community pharmacy, we first need to have an understanding of what is causing the pain, how severe the pain is, and how long it has been. Generally, acute pain — for example, from injuries — is the only type of pain that should be treated over the counter in pharmacy, while chronic pain should first be investigated by a doctor. It is important to get pain management right by recommending effective and appropriate products, so that we can have the best treatment outcomes for our patients.

Usually burns, bruises and cuts are easy to distinguish and are examples of acute pain — that is, pain which will resolve as the damage heals1. Acute pain might be confined to a joint or particular muscle as in sprains and strains. Knowing the location of the pain can help you decide whether topical therapy is appropriate, or refine your choices of analgesics, depending on what has caused the pain. It can also help determine if a referral is necessary — sudden acute pain with no obvious cause could indicate a problem which requires urgent medical attention, as would anything that made you suspect broken bones.

Severity of pain can be a combination of physical, physiological and psychological aspects. Research has shown that anxiety and emotional distress can worsen a patient’s perception of pain, so making the patient feel comfortable and welcome in the pharmacy can be a good start2. It will help to assess the severity by asking the patient to rate their level of pain from 1–10. When speaking to the patient you might also ask them to describe the kind of pain — is it dull, throbbing, aching, sharp? This can help you decide whether to refer the patient or start with stronger analgesics.

Pain will usually persist until the stimulus causing the pain is removed or the underlying cause has healed or been treated — acute pain will typically begin to resolve within 48 hours. Those who have not improved within this time frame should be referred. Where there is no obvious factor causing the pain, or where an injury has seemingly healed but pain persists, a treat and refer approach might be appropriate, but the patient will need to have the cause of the pain properly investigated as soon as possible.

Treating pain
Treatment in the pharmacy will typically depend on patient preference, the above factors of location and severity, and pharmacist recommendation. Typical first-line therapy is paracetamol, though you may also choose to add either topical or oral NSAIDs such as ibuprofen or diclofenac. Topical products can be useful for localised muscle pain but may not be as effective for joint pain.

Also consider the likelihood or impact of adverse reactions. For paracetamol, a big problem is confusion for people taking other products with paracetamol, such as cold and flu medicine, and inadvertently overdosing. For NSAIDs, medical conditions such as asthma, hypertension, kidney problems and reflux need to be weighed against the adverse effect profiles of these medicines. In some cases short-term NSAID use may still be considered safe when compared to the benefits.

Pharmacist only products can also be initiated for short-term use in acute pain. Combination paracetamol and ibuprofen products are often an effective choice, and carry no risk of abuse like codeine combination products. Schedule 3 codeine products are often requested by patients; however, there is a distinct lack of evidence that they are any more effective than equivalent doses of paracetamol or an NSAID alone. Research has suggested that a minimum dose of 30 mg of codeine is required for effective pain relief in combination products3. This is less than most Schedule 3 products, so if you are able to start a discussion with your patient, you may be able to offer them products which are safer and just as effective.

Selecting the right product
Even with a direct product request, it is still essential to ensure that a product is appropriate and safe for the patient by checking their other medications or medical conditions and allergies. Assessing the cause and severity of the pain can help determine the kind of treatment you might initiate and also whether a referral is necessary. Choose the right product, or range of products, for the individual and you will achieve the best patient outcomes.

1. ANZCA & Faculty of Pain Medicine (2007). Updates for Acute Pain Management: Scientific Evidence. 2nd Edition.
2. Van Der Lugt, C. Rollman, A. Naeije, M. Lobbezoo, F. Visscher, C. (2012). Social support in chronic pain: development and preliminary psychometric assessment of a new instrument. Journal of Oral Rehabilitation. 39(4):270-276.
3. Murnion, B. (2010). Combination analgesics in adults. Australian Prescriber. 33:113-115.

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