The final publication of NICE’s first-ever guideline on chronic pain has recommended that GPs should ‘encourage and support’ patients to stop taking opioids in certain cases.
It confirmed recommendations made in draft guidance, published in August, which said that GPs should not prescribe commonly-used medicines including opioids and gabapentinoids to patients with chronic primary pain because they could be ‘harmful’.
GPs should consider alternatives such as certain antidepressants, an exercise programme, CBT or acupuncture, it reiterated.
NICE said that GPs should not initiate any of the following to patients aged 16 or over with chronic primary pain:
- antiepileptic drugs including gabapentinoids, unless gabapentinoids are offered as part of a clinical trial for complex regional pain syndrome
- antipsychotic drugs
- corticosteroid trigger point injections
- local anaesthetics (topical or intravenous), unless as part of a clinical trial for complex regional pain syndrome
- local anaesthetic/corticosteroid combination trigger point injections
- non-steroidal anti-inflammatory drugs
However, while the draft guidance said GPs should ‘explain the risks of continuing’ to patients already taking them, the final guidance said they should ‘review the prescribing as part of shared decision making’.
It said: ‘[GPs should] explain the lack of evidence for these medicines for chronic primary pain and agree a shared plan for continuing safely if they report benefit at a safe dose and few harms – or explain the risks of continuing if they report little benefit or significant harm, and encourage and support them to reduce and stop the medicine if possible.’
GPs should also discuss ‘problems associated with withdrawal’ with the patient, it added.
NICE said: ‘The committee agreed that when recommendations had been made against the use of medicines, there should be guidance for people who are already taking these, including guidance for those who report benefit from these medicines (this includes pain medicines bought over the counter).
‘They therefore included a recommendation based on expert opinion to explain the risks of continuing a medicine, to inform a decision about whether the risks outweighed the benefits and whether the medicine should be reduced or stopped, or continued safely.’
Meanwhile, the final guideline also said that antidepressants should be considered for those aged 18 years or over to manage chronic primary pain ‘after a full discussion of the benefits and harms’.
However, while the draft guideline recommended this for over-16s, the final document says GPs should ‘seek specialist advice’ if they are considering the use of antidepressants for young people aged 16-17.
The new document also emphasised the need for ‘appropriate training’ for those delivering acceptance and commitment therapy (ACT), cognitive behavioural therapy (CBT) or acupuncture.
Acupuncture does not need to be delivered in a community setting or by a band 7 or lower healthcare professional, but can be provided by another healthcare professional with ‘appropriate training’ and in another setting for ‘equivalent or lower cost’, it added.
The guideline also recommended further research in the clinical and cost-effectiveness of the following for managing chronic primary pain in patients aged over 16:
- Mindfulness therapy
- Cognitive behavioural therapy (CBT) for insomnia or CBT for insomnia and pain
- Manual therapy
- Repeat courses of acupuncture or dry needling
- Psychodynamic psychotherapy
- Relaxation therapies
- Laser therapy
- Transcranial magnetic stimulation
And it recommended further research into the clinical and cost-effectiveness of gabapentinoids or local anaesthetics for managing complex regional pain syndrome in the over-16s.
It reiterated that NICE is developing a guideline on medicines associated with dependence or withdrawal symptoms, due to be published in November 2021.
Chronic primary pain is defined as pain that persists or recurs for more than three months which has no clear underlying cause or is ‘out of proportion to any observable injury or disease’, NICE said.
The prevalence is unknown but estimated to be between 1% and 6% in England, it added.
When the draft guidance was published, GP leaders warned that a ‘lack of access’ to alternative interventions must be addressed in order for them to benefit patients with chronic pain.
NICE chronic pain recommendations
1.2 Managing chronic primary pain
This section covers managing chronic primary pain (in which no underlying condition adequately accounts for the pain or its impact). Chronic primary pain and chronic secondary pain can coexist.
Non-pharmacological management of chronic primary pain
Exercise programmes and physical activity for chronic primary pain
1.2.1 Offer a supervised group exercise programme to people aged 16 years and over to manage chronic primary pain. Take people’s specific needs, preferences and abilities into account.
1.2.2 Encourage people with chronic primary pain to remain physically active for longer-term general health benefits (also see NICE guidelines on physical activity and behaviour change: individual approaches).
Psychological therapy for chronic primary pain
1.2.3 Consider acceptance and commitment therapy (ACT) or cognitive behavioural therapy (CBT) for pain for people aged 16 years and over with chronic primary pain, delivered by healthcare professionals with appropriate training.
1.2.4 Do not offer biofeedback to people aged 16 years and over to manage chronic primary pain.
Acupuncture for chronic primary pain
1.2.5 Consider a single course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system, for people aged 16 years and over to manage chronic primary pain, but only if the course:
• is delivered in a community setting and
• is delivered by a band 7 (equivalent or lower) healthcare professional with appropriate training and
• is made up of no more than 5 hours of healthcare professional time (the number and length of sessions can be adapted within these boundaries) or
• is delivered by another healthcare professional with appropriate training and/or in another setting for equivalent or lower cost.
Electrical physical modalities for chronic primary pain
1.2.6 Do not offer any of the following to people aged 16 years and over to manage chronic primary pain because there is no evidence of benefit:
• interferential therapy.
Pharmacological management of chronic primary pain
1.2.7 Consider an antidepressant, either amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline, for people aged 18 years and over to manage chronic primary pain, after a full discussion of the benefits and harms.
In April 2021, this was an off-label use of these antidepressants. See NICE’s information on prescribing medicines.
1.2.8 Seek specialist advice if pharmacological management with antidepressants is being considered for young people aged 16 to 17 years.
1.2.9 If an antidepressant is offered to manage chronic primary pain, explain that this is because these medicines may help with quality of life, pain, sleep and psychological distress, even in the absence of a diagnosis of depression.
1.2.10 Do not initiate any of the following medicines to manage chronic primary pain in people aged 16 years and over:
• antiepileptic drugs including gabapentinoids, unless gabapentinoids are offered as part of a clinical trial for complex regional pain syndrome (see the recommendation for research on pharmacological interventions)
• antipsychotic drugs
• corticosteroid trigger point injections
• local anaesthetics (topical or intravenous), unless as part of a clinical trial for complex regional pain syndrome (see the recommendation for research on pharmacological interventions)
• local anaesthetic/corticosteroid combination trigger point injections
• non-steroidal anti-inflammatory drugs
Pregabalin and gabapentin (gabapentinoids) are Class C controlled substances (under the Misuse of Drugs Act 1971) and scheduled under the Misuse of Drugs Regulations 2001 as Schedule 3. Evaluate patients carefully for a history of drug misuse before prescribing and observe patients for development of signs of misuse and dependence (MHRA Drug Safety Update April 2019).
1.2.11 If a person with chronic primary pain is already taking any of the medicines in recommendation 1.2.10, review the prescribing as part of shared decision making:
• explain the lack of evidence for these medicines for chronic primary pain and
• agree a shared plan for continuing safely if they report benefit at a safe dose and few harms or
• explain the risks of continuing if they report little benefit or significant harm, and encourage and support them to reduce and stop the medicine if possible.
1.2.12 When making shared decisions about whether to stop antidepressants, opioids, gabapentinoids or benzodiazepines, discuss with the person any problems associated with withdrawal.
1.2.13 For recommendations on stopping or reducing antidepressants, see the NICE guideline on depression in adults.
1.2.14 For recommendations on reviewing treatments, see the NICE guidelines on medicines optimisation and medicines adherence.
NICE is developing a guideline on medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults.
1.2.15 For recommendations on cannabis-based medicinal products, including recommendations for research, see the NICE guideline on cannabis-based medicinal products.