NICE has published new guidance on the assessment and management of chronic pain recommending that patients should not be started on commonly used drugs and instead non-pharmacological management should be considered.

The guideline covers all types of chronic pain including chronic primary pain and chronic secondary pain. Primary chronic pain is pain with no clear underlying cause whereas secondary chronic pain is caused by an underlying condition such as osteoarthritis, rheumatoid arthritis, ulcerative colitis, or endometriosis.

In the UK the prevalence of chronic pain is uncertain, but appears common, affecting perhaps one-third to one-half of the population. The prevalence of chronic primary pain is unknown but is estimated to be between 1 and 6% in England. 

The Royal College of GPs has said that patchy access to alternative pain treatment needs to be addressed ‘urgently’ for new guidelines to benefit patients. It added that 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.

Professor Martin Marshall, Chair of the Royal College of GPs, said: "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."

Understand how pain is affecting a person’s life 

The guideline 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 also 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.

Dr Paul Chrisp, director of the Centre for Guidelines at NICE, said: “We want this guideline to make a positive difference to people with chronic pain, and their families and carers.

“It highlights that achieving an understanding of how pain is affecting a person’s life and those around them and knowing what is important to the person is the first step in developing an effective care and support plan that recognises and treats a person’s pain as valid and unique to them.”

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.

The guideline makes recommendations for treatments that 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.

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

The guideline does recommend that an antidepressant can be considered for people aged 18 years and over to manage chronic primary pain, after a full discussion of the benefits and harms. This is because the evidence shows antidepressants may help with quality of life, pain, sleep and psychological distress, even in the absence of a diagnosis of depression.

Balance between benefits of pain drugs and the risks associated with them

Dr Chrisp added: “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.”

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 guideline underlines the importance of appropriate assessment, careful drug choice, exercise programmes, psychological therapies, and consideration of acupuncture in improving the experience and outcomes of care for people with chronic pain.”

NICE is also producing guidelines on shared decision making and the safe prescribing and withdrawal management of medicines associated with dependence or withdrawal symptoms; these are expected to be published in June 2021 and November 2021 respectively.