National Institute for Health and Care Excellence
A number of commonly used drug treatments for chronic primary pain have little or no evidence that they work and shouldn’t be prescribed, NICE has said in its draft clinical guideline published on the assessment and management of chronic pain in over 16s.
Instead, the draft guideline, which is now open to public consultation until 14 September 2020, says that people with a type of chronic pain called chronic primary pain should be offered supervised group exercise programmes, some types of psychological therapy, or acupuncture.
Chronic primary pain represents chronic pain as a condition in itself and which can’t be accounted for by another diagnosis, or where it is not the symptom of an underlying condition (this is known as chronic secondary pain). It is characterised by significant emotional distress and functional disability. Examples include chronic widespread pain and chronic musculoskeletal pain, as well as conditions such as chronic pelvic pain.
The draft guideline emphasises the importance of putting the patient at the centre of their care, and of fostering a collaborative, supportive relationship between patient and healthcare professional. It also highlights the role of good communication and its impact on the experience of care for people with chronic pain.
The draft guideline recommends that some antidepressants can be considered for people with chronic primary pain. However, it says that paracetamol, non-steroidal anti-inflammatory drugs (these include aspirin and ibuprofen), benzodiazepines or opioids should not be offered. This is because, while there was little or no evidence that they made any difference to people’s quality of life, pain or psychological distress, there was evidence that they can cause harm, including possible addiction.
The draft guideline also says that antiepileptic drugs including gabapentinoids, local anaesthetics, ketamine, corticosteroids and antipsychotics should not be offered to people to manage chronic primary pain. Again, this was because there was little or no evidence that these treatments work but could have possible harms.
Acupuncture is recommended as an option for some people with chronic primary pain, provided it is delivered within certain, clearly defined parameters.
Chronic pain is often difficult to treat and can have a significant impact on individuals and their families and carers. Estimates suggest that chronic pain may affect between one-third and one-half of the population, although it is not known what proportion of people meeting the criteria for chronic pain either need or wish to have treatment. Almost half of people with chronic pain have a diagnosis of depression and two-thirds of people are unable to work because of it.
Paul Chrisp, director of the Centre for Guidelines at NICE, said: “What this draft guideline highlights is the fundamental importance of good communication to the experience of care for people with chronic pain. When many treatments are ineffective or not well tolerated it is important to get an understanding of how pain is affecting a person’s life and those around them because knowing what is important to the person is the first step in developing an effective care plan.
“Importantly the draft guideline also acknowledges the need for further research across the range of possible treatment options, reflecting both the lack of evidence in this area and the need to provide further choice for people with the condition.”
Nick Kosky, a consultant psychiatrist at Dorset HealthCare NHS University Foundation Trust and chair of the guideline committee said: “Understandably, people with chronic pain expect a clear diagnosis and effective treatment. But its complexity and the fact GPs and specialists alike find chronic pain very challenging to manage, means this is often not possible. This mismatch between patient expectations and treatment outcomes can affect the relationship between healthcare professionals and patients, a possible consequence of which is the prescribing of ineffective but harmful drugs.
“This guideline, by fostering a clearer understanding of the evidence for the effectiveness of chronic pain treatments, will help to improve the confidence of healthcare professionals in their conversations with patients. In doing so it will help them better manage both their own and their patient’s expectations.”