Don't start people with chronic primary pain on commonly used drugs including paracetamol, NSAIDs, benzodiazepines or opioids, says NICE guideline

NICE guideline does recommend however that an antidepressant can be considered after a full discussion of the benefits and harms.

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People with chronic primary pain (in which no underlying condition adequately accounts for the pain or its impact) should be offered a range of treatments to help them manage their condition, NICE has said in its guideline on the assessment and management of chronic pain (primary and secondary) published today.

The guideline makes recommendations for interventions which it says have been shown to be effective in managing chronic primary pain. These include exercise programmes and the psychological therapies CBT and acceptance and commitment therapy (ACT). Acupuncture is also recommended as an option, provided it is delivered within certain clearly defined parameters.

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People with chronic primary pain should not be started on commonly used drugs including paracetamol, non-steroidal anti-inflammatory drugs, benzodiazepines or opioids. NICE says this is because, while there is little or no evidence that they make any difference to people’s quality of life, pain or psychological distress, they can cause harm, including possible addiction. 

The guideline does recommend that an antidepressant can be considered, either amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline, for people aged 18 years and over to manage chronic primary pain, after a full discussion of the benefits and harms. According to NICE, the evidence shows antidepressants may help with quality of life, pain, sleep and psychological distress, even in the absence of a diagnosis of depression.

The guideline also emphasises the need for shared decision making, putting patients at the centre of their care, and fostering a collaborative, supportive relationship between patients and healthcare professionals. It highlights the importance of healthcare professionals gaining an understanding of how a person’s life affects their pain and how pain affects their life, including their work and leisure time, relationships with family and friends, and sleep.

The guideline recommends that a care and support plan should be developed based on the effects of pain on day-to-day activities, as well as a person’s preferences, abilities and goals. It also highlights the importance of being honest with the person about the uncertainty of the prognosis.

Dr Paul Chrisp, director of the Centre for Guidelines at NICE, said: “This guideline is very clear in highlighting that, based on the evidence, for most people it’s unlikely that any drug treatments for chronic primary pain, other than antidepressants, provide an adequate balance between any benefits they might provide and the risks associated with them.

“But people shouldn’t be worried that we’re asking them to simply stop taking their medicines without providing them with alternative, safer and more effective options. First and foremost, people who are taking medicines to treat their chronic primary pain which aren’t recommended in the guideline should ask their doctor to review their prescribing as part of shared decision making. This could involve agreeing a plan to carry on taking their medicines if they provide benefit at a safe dose and few harms, or support for them to reduce and stop the medicine if possible. When making shared decisions about whether to stop it's important that any problems associated with withdrawal are discussed and properly addressed.”

Responding to the publication of the new clinical guidelines for chronic primary pain, Professor Martin Marshall, Chair of the Royal College of GPs, said: "Pain can cause untold misery for patients and their families."

"As GPs, we want to be able to help patients manage their pain and live as normal a life as possible, but chronic primary pain - pain with no known underlying cause - can be challenging to manage in general practice, and the College has been calling for guidelines to address this for some time. It is important to note that all forms of chronic pain normally have persisted for three months or more for the diagnosis to have been made; pain of a shorter duration may need different treatment.

"GPs will always take a holistic approach to delivering care, considering physical, psychological and social factors when making a diagnosis and developing a treatment plan in partnership with our patients, so the patient-centred approach to this guideline is welcome.

"We also understand the move away from a pharmacological option to treating chronic primary pain to a focus on physical and psychological therapies that we know can benefit people in pain. However, access to these therapies can be patchy at a community level across the country, so this needs to be addressed urgently, if these new guidelines are to make a genuine difference to the lives of our patients with primary chronic pain.

"It's also key that the guidelines advise against starting drug-therapy for patients who have chronic primary pain - but not to stop medication already being taken, particularly if they report some benefit.

“Patients who have been prescribed medication for their pain should not stop taking medication that has been prescribed to them. If they are concerned, they should discuss this with their doctor at their next medication review, where alternatives to their treatment plan can be discussed.”


Editorial team, Wilmington Healthcare

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I have strong reservations on use of Opioids and gabapentinoids in management of chronic pain. There is no evidence of any benefit in chronic pain and there are serious potentials of harm in long term. However, Primary or secondary or even psychological, pain is Real to patients. So it would be extremely unreal trying to convince our patients that they don't need any medications?