Consider a range of treatments in chronic primary pain

CHRONIC pain where the cause is unclear should not be managed solely with medications such as paracetamol, non-steroidal anti-inflammatory drugs, benzodiazepines or opioids, according to new guidance published by NICE.

People with such pain should be offered a range of treatments to help them manage their condition.

NICE defines pain that lasts for more than three months as “chronic or persistent”, and prevalence in the UK is uncertain but it appears to affect one-third to one-half of the population. Chronic pain that is caused by an underlying condition (for example, osteoarthritis or endometriosis) is known as “chronic secondary pain”, whereas pain with an unclear cause it is called “chronic primary pain”. The new NICE guideline is focused mainly on the latter – with an estimated prevalence in England of between one and six percent.

NICE says that people with chronic primary pain should not be started on commonly used pain medications, as 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 new guideline makes recommendations for treatments that have been shown to be effective in managing chronic primary pain, including exercise programmes and psychological therapies, such as CBT (Cognitive behavioural therapy). The guideline emphasises the need for shared decision-making and highlights the importance of gaining an understanding of "how a person’s life affects their pain and how pain affects their life", including work and leisure time, relationships with family and friends, and sleep.

NICE recommends personalised care and support plans based on the effects of pain on day-to-day activities, as well as personal preferences, abilities and goals, and highlights the importance of being honest with the person about the uncertainty of the prognosis.

Antidepressants can be considered for people aged 18 years and over to manage chronic primary pain, after a full discussion of the benefits and harms. Evidence shows antidepressants may help with quality of life, pain, sleep and psychological distress, even in the absence of a diagnosis of depression.

Dr Paul Chrisp, director of the Centre for Guidelines at NICE, said: "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."

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

Link: Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain