Mixed-methods evaluation of a nurse-pharmacist managed pain clinic

Background: Under-treatment of chronic pain within the community is a global problem. There is a growing interest to evaluate the role of nurses and pharmacists in chronic pain management with an aim to improve access to and quality of pain services. Aim: The research presented in this thesis had two aims: first, to evaluate the effectiveness of pharmacist-led medication review in chronic pain management; second, to evaluate the impact of a community based nurse-pharmacist managed pain clinic. Methods: A systematic review and meta-analysis was conducted to evaluate the effectiveness of pharmacist-led medication review in chronic pain management. For the second aim, a mixed-methods study consisting of a quasi-experimental design and a qualitative descriptive design was undertaken. Pain intensity was the primary outcome. The secondary outcomes included: physical functioning; emotional functioning; quality of life; chronic pain grade and patient satisfaction. Patient satisfaction was evaluated using face-to-face, semi-structured qualitative interviews. Results: Of the 578 papers screened, five RCTs were included in the systematic review and three in the meta-analysis. Compared to the control, the meta-analysis found that patients in the intervention group had: a statistically significant reduction in pain intensity of 0.8 point (95% CI -1.28 to -0.36) and 0.7 point (95% CI -1.19 to -0.20) at 3-months and 6-months respectively; and 4.84 point (95% CI, -7.38 to -2.29) at 3-months and -3.82 point (95% CI, -6.49 to -1.14) at 6-months improvement in physical functioning. Seventy nine patients with a mean age of 46.5 years (SD ±14.4) took part in the quasi-experimental study. Thirty-six and 9 patients completed discharge and 3-month follow-up assessments respectively. Compared to baseline, statistically significant reductions were noted for two of the four outcome measures: pain intensity (P=0.02), and interference of pain with physical functioning (P=0.02) on discharge from the service. The majority of the patients were, in general, satisfied with the service. Four contributing factors to patient satisfaction were identified: ample consultation time; in-depth specialised knowledge; listening and understanding to patients’ needs; and a holistic approach. Conclusion: Community-based pain clinics managed by a nurse and pharmacist have the potential to improve chronic pain management in the community by providing timely access to a specialised pain service, ensuring safe and effective use of analgesics (medication reviews) and promoting self-management (patient education). Both pharmacist-led medication review and nurse-pharmacist managed pain clinics can reduce pain intensity and improve physical functioning The long term impact of the pain clinic could not be fully elucidated from this research as the planned follow-up data collection could not be completed due to decommissioning of the service.