A rethink of our approach to chronic pain is desperately needed

Chronic pain places a huge burden on millions of patients, families and carers in Great Britain. However, despite being such a prevalent condition, the tools for managing it are unfortunately blunt.

Pharmacological options — such as opioid analgesics — have traditionally been the first port of call in this area, but there are well-known problems with this treatment option. Although a small percentage of patients may find opioids effective for chronic pain, a 2019 review by Public Health England has concluded that, for most people with chronic non-cancer pain, opioids do not provide adequate clinical benefit when balanced against the risks of dependence and overdose poisoning, and harm to others in the community. 

There are similar problems with other classes of drugs. Gabapentinoids are recommended by the National Institute for Health and Care Excellence (NICE) for neuropathic pain, but there are concerns over their misuse.

NICE also recommends the antidepressants amitriptyline and duloxetine for neuropathic pain, although amitriptyline is associated with several adverse effects and is dangerous in overdose. Duloxetine has greater relative safety in overdose and more tolerable side effects, but, nevertheless, around one in six people discontinue this medicine because of its side effects.

Seasoned pharmacists will remember the Vioxx scandal in the early 2000s, which highlighted the side effects associated with cyclooxygenase-2 inhibitors, leading to a re-evaluation of the whole non-steroidal anti-inflammatory drug (NSAID) class. NICE now says that oral NSAIDs can be considered for lower back pain, but they should be used at the lowest dose for the shortest possible duration of time.

Many experts say that the current model for the treatment of chronic pain is broken. The use of stronger analgesics to treat chronic pain gained popularity in the 1990s following inappropriate adoption of the World Health Organization’s analgesic ladder, which was originally developed amid heavy marketing from pharmaceutical companies around treatments for cancer-related pain.

Moving to a model where more patients with chronic pain can access non-drug alternatives should help lead to better success rates

We are now faced with a situation where patients often expect to be prescribed medicines that will treat their chronic pain, assuming that because they work in relieving acute pain, they will experience a similar effect. However, this perception inevitably leads to disappointment.

GPs now have few options to prescribe and limited time to spend with patients to adjust their expectations. As shown in our investigation this month, specialist pain management services have adapted to offer more holistic care for patients, such as psychological interventions, exercise programmes and physiotherapy. But long waits — for years or more in some cases — mean that patients can deteriorate significantly before receiving the help they need.

Perhaps with the advent of primary care networks in England, this will finally be tackled. Moving to a model where  patients with chronic pain can access non-drug alternatives and counselling quickly should help lead to better success rates. Linking in community pharmacy with this effort is crucial too, since many patients with chronic pain will be buying over-the-counter analgesics.

However, perhaps the major change we need first is a campaign to manage patients’ expectations about drug treatment for chronic pain, explaining that rehabilitation is not a denial of pain but a way of living with it. That will require more resources in order to ensure that GPs, nurses or practice pharmacists can spend the time needed with patients.

A draft version of the new NICE guideline for the assessment and management of chronic pain is due to be published on 21 February 2020, and we hope that this will point towards a new way of managing chronic pain. It is desperately needed.