Patients with chronic primary pain should be offered non-pharmacological options as most commonly used drug treatments for chronic primary pain have little or no evidence that they work, according to new draft NICE guidance.

The draft guidance says that paracetamol, non-steroidal anti-inflammatory drugs (these include aspirin and ibuprofen), benzodiazepines or opioids should not be offered.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

It does recommend that some antidepressants can be considered for people with chronic primary pain. Instead patients should be offered supervised group exercise programmes, some types of psychological therapy, or acupuncture.

Chronic primary pain include chronic widespread pain and chronic musculoskeletal pain, as well as conditions such as chronic pelvic pain. It 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 and almost half of people with chronic pain have a diagnosis of depression and two-thirds of people are unable to work because of it.

Mismatch between patient expectations and treatment outcomes 

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 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.

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.” 

The draft guideline is now open to public consultation until 14 September 2020.