Editor's note, 5 August 2020: This article was updated to include additional comment.
Paracetamol, NSAIDs (including aspirin and ibuprofen), benzodiazepines, and opioids, should not be offered for chronic primary pain in over-16s, according to new National Institute for Health and Care Excellence (NICE) draft guidance.
The Royal College of GPs said 'patchy' access to specialist psychological therapies or pain management clinics needed to be addressed for the new guidance to work.
NICE estimates around 31% of the population may be affected by chronic pain, and says almost half of those with chronic pain also have a diagnosis of depression, and two-thirds are unable to go out to work because of it.
Evidence
The draft NICE guidance said there was little or no evidence that paracetamol, non-steroidal anti-inflammatory drugs, benzodiazepines or opioids made any difference to quality of life, pain, or psychological distress, in conditions including chronic widespread pain, chronic musculoskeletal pain, and chronic pelvic pain. However, there was evidence harms were possible, including addiction.
Some antidepressants can still be considered, including duloxetine, fluoxetine, paroxetine, citalopram, sertraline, and amitriptyline.
Antiepileptic drugs (including gabapentinoids), local anaesthetics, ketamine, corticosteroids, and antipsychotics, should not be offered for chronic primary pain.
Where patients are already prescribed any of these treatments, conversations should be held to explain the risks, and the problems related to withdrawal of treatment.
Recommended treatment options include supervised group exercise, acupuncture, and some psychological therapies, including acceptance and commitment therapy (ACT), and cognitive behavioural therapy (CBT).
There was not enough evidence to support manual therapy, social interventions, biofeedback, relaxation therapy, or hypnosis, or TENS, ultrasound and interferential therapy.
Specific chronic pain guidance already exists for those with secondary chronic pain due to conditions such as endometriosis, osteoarthritis, and low back pain.
'Challenging to Manage'
NICE acknowledged chronic pain is often difficult to treat and can have a significant impact on individuals and their families and carers.
In a statement, Paul Chrisp, director of the Centre for Guidelines at NICE, said the guideline highlighted the importance of good communication with patients. "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," he said.
"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."
Chair of the guideline committee, Consultant Psychiatrist at Dorset HealthCare NHS University Foundation Trust, Nick Kosky, added: "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."
GPs' Reaction
In a statement RCGP Chair Professor Martin Marshall said: "Diagnosing and managing the care of patients in chronic pain can be challenging in general practice, not least because in many cases pain starts as an acute problem, which becomes chronic at a later stage. Once diagnosis has been made, there is also currently a lack of access to some of the evidence-based interventions, that could be of benefit for patients, recommended in these guidelines.
"GPs and our teams are aware that prescribing pain medication to patients comes with risks, including addiction, and this is something we will discuss with them when developing a treatment plan – and as part of subsequent medication reviews. Most patients in pain do not want to take medication long-term, and GPs do not want this either, but sometimes medication has been the only thing that brings relief. As such these new guidelines, which focus on alternative therapies, have the potential to be beneficial for patients - but they will need to be guaranteed appropriate access to them. We should also be mindful not to disregard some medications completely as a lack of evidence may be due to a lack of high-quality research, particularly for older drugs, such as paracetamol.
"GPs are open to alternatives, as long as there is evidence of their benefit and effectiveness, and already do explore treatments for chronic pain, such as referrals to psychological therapies or pain management clinics, but currently access is patchy at community level across the country. Therefore, any NICE guidance that suggests an alternative to medication must go hand-in-hand with adequate access to them at community level in order to really make a difference to the lives of our patients living in chronic pain."
The charity Pain Concern said in a statement: "We welcome the guidance on collaborative working between patients and health care professionals. However, we are aware of the anxiety that the recommendations are likely to raise amongst people living with chronic pain who rely on these medicines to cope, and we will carefully consider this in our response to the draft guidelines."
The guidance is open to consultation until 14 August 2020.
