Common pain medicines — such as paracetamol, non-steroidal anti-inflammatory drugs including aspirin and ibuprofen, benzodiazepines, and opioids — should not be offered to patients with chronic primary pain, according to National Institute for Health and Care Excellence (NICE) draft guidance.
But exercise, psychological therapies such as cognitive behavioural therapy (CBT), and acupuncture should be offered, says the draft guidance, published on 4 August 2020.
The guidance, on managing chronic pain in patients aged over 16, concluded that there was little evidence that many of the commonly prescribed drugs made a difference to the patient’s quality of life — but that there was evidence they can lead to problems, including the risk of addiction.
It also recommends avoiding the use of antiepileptic drugs, including gabapentinoids, again because of “limited evidence” that they offer relief. But it says that certain antidepressants, such as commonly prescribed selective serotonin reuptake inhibitors, can be prescribed off-label after patient and prescriber have had a “full discussion of the benefits and risks”.
The guidance recommends a range of non-pharmacological interventions for chronic primary pain management, including group exercise; psychological therapies, including acceptance and commitment therapy and CBT; and acupuncture. The latter, it said, should be delivered by a band 7 (or lower) healthcare professional.
Chronic primary pain is a condition that persists for longer than three months and is associated with significant emotional distress or functional disability and that cannot be explained by another chronic condition. This includes conditions such as fibromyalgia, complex regional pain syndrome, chronic migraine, irritable bowel syndrome and non-specific low-back pain.
Wing Tang, head of professional standards at the Royal Pharmaceutical Society, said: “The recommendations presented in this draft guidance should be looked at carefully and we will consider the underlying evidence.
“Pharmacists are often the first port of call in helping those with chronic and acute pain and will always want to provide the best possible advice, based upon the latest evidence, to support people to manage pain.”
Martin Marshall, chair of the Royal College of General Practitioners, said there was currently “a lack of access to some of the evidence-based interventions” recommended in the guidance.
“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,” he said.
Marshall added that the recommendations for “alternative therapies” in the guidance have the potential to benefit 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.”
The draft guidance is open for consultation until 14 September 2020.
Correction: The headline of this article was changed on the 05 August 2020 to make clear that the treatment advice in this draft guideline on chronic pain relates to chronic primary pain, rather than all chronic pain, as the article later explains.