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New draft guidelines published by the National Institute for Health and Care Excellence (NICE) say that for patients aged over 16, chronic primary pain conditions should be managed through exercise, psychological therapy and acupuncture, and not by a host of common drugs.
Those drugs and groups of drugs named are:
- Non-steroidal anti-inflammatory drugs;
- Local anaesthetics;
- Local anaesthetic/corticosteroid combinations;
The guidance also recommends avoiding “electrical physical modalities” such as TENS, ultrasound and interferential therapy.
What is chronic primary pain?
The 2019 update to the World Health Organization’s International Classification of Diseases (ICD-11), includes chronic pain for the first time. Under the new criteria, chronic pain is classified as either chronic primary pain or chronic secondary pain.
Chronic primary pain is defined as where pain has persisted for more than three months and is associated with significant emotional distress and/or functional disability, and the pain is not better accounted for by another condition. Typical examples of chronic primary pain conditions are Complex Regional Pain Syndrome (CRPS), Fibromyalgia (FM), Irritable Bowel Syndrome (IBS), non-specific low-back pain and chronic migraine.
What reasons have NICE given?
NICE say that there is little evidence that prescribing these drugs makes any difference to a person’s quality of life. Conversely, they point to side-effects including, in some instances, the risk of addiction.
What do NICE recommended in their place?
NICE does list a number of antidepressants – Duloxetine, Fluoxetine, Paroxetine, Citalopram, Sertraline and Amitriptyline – which may be used “off label” following “a full discussion of the benefits and risks”. The NHS describes “off label” use as when “the medicine has a license for treating some conditions, but that the manufacturer of the medicine has not applied for a license for it to be used to treat your condition.” A good example is Amitriptyline, which is more usually prescribed to treat depression. However, it is also used off-label to treat anxiety, IBS, and chronic pain.
Other than antidepressants though, NICE recommends:
- a “supervised group exercise programme (for example, cardiovascular, mind–body, strength, or a combination of approaches)” taking “people’s specific needs, preferences and abilities into account.”
- considering “acceptance and commitment therapy (ACT) or cognitive–behavioural therapy (CBT)”;
- considering “a course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system”.
Anger and concern
While the draft guidance has been published as a consultation document only, it has, understandably, provoked a passionate response on social media from many people suffering chronic primary pain conditions. Indeed, some suggest that it takes the war on opioids to yet another level. One correspondent writes:
“I have been a pharmacist for 36 years with a wide and fulfilling career…I am also a chronic pain sufferer…The impact of this is beyond the comprehension of those who sit on NICE panels. They consider evidence-based medicine only. Patients’ experiences with pain are not evidence based, so are irrelevant to those pen pushers. I am a scientist by nature and have strong confidence in evidence-based medicine when it is practiced with patient factors as a consideration. In my case I have to rely on paracetamol and codeine for pain, to find a happy medium with IBS…I rely on physical mobilisation and trying to keep a positive mental attitude. I have tried acupuncture without success…The pain has given way to depression…I take an antidepressant mentioned in the guidelines to get through the days. It may relieve pain to a degree (who knows), but I need to rely on the pain medication, despite my best effort to get by without.”
British Pain Society
The British Pain Society, which largely comprises professionals working in and associated with the field of pain medicine, has published a statement on the draft guidelines. They conclude:
“What seems to be of greater importance to the Society is the clinical identification of all of the conditions present in an individual patient by primary or secondary care healthcare practitioners, with onward referral to speciality teams in Pain Medicine in cases of doubt, in order to tailor treatment and improve the quality of life for that individual patient.
“The Society finds blanket diagnostic labelling of patients or indiscriminate withdrawal of pain treatments therapy to be unhelpful and potentially harmful. These could lead to unnecessary distress and suffering in the large number of chronic pain patients in the British population.”