The first-ever NICE guideline on chronic pain has said that GPs should not prescribe opioids to patients with chronic pain because they could be ‘harmful’.
Instead, GPs should consider alternatives such as certain antidepressants, an exercise programme, CBT or acupuncture.
Published today, the long-awaited draft guidance says GPs should avoid prescribing commonly used medicines including opioids and gabapentinoids because there was limited evidence of their effectiveness in managing chronic pain.
However, there was evidence that they could be ‘harmful’ to patients and cause addiction, NICE added.
The guidance, which is open for consultation until 14 August, said: ‘The lack of evidence for effectiveness of opioids, along with evidence of long-term harm, persuaded the committee to recommend against opioid use for people with chronic primary pain.
‘Although there were limitations, evidence from non-randomised studies on the long-term use (more than six months) of opioids for chronic pain suggested an increased risk of dependence.’
It added: ‘Based on their experience, the committee agreed that even short-term use of opioids could be harmful for a chronic condition.’
NICE said GPs should not offer the following to patients aged 16 or over with chronic primary pain – defined as pain that persists or recurs for more than three months – ‘by any route’:
- non-steroidal anti-inflammatory drugs
- anti-epileptic drugs including gabapentinoids, unless gabapentinoids are offered as part of a clinical trial for complex regional pain syndrome
- local anaesthetics, by any route, unless as part of a clinical trial for complex regional pain syndrome
- local anaesthetic/corticosteroid combinations
GPs should explain the ‘risks of continuing’ to those already taking any of these medicines, the document said.
It added: ‘If a shared decision is made to stop antidepressants, opioids, gabapentinoids or benzodiazepines, be aware of the problems associated with withdrawal.’
It is separately developing a guideline on medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management, but this is not expected until November 2021.
When assessing all types of chronic pain, NICE advised that GPs ask a series of questions of patients and develop a care plan with the patient to suit their needs, fostering ‘a collaborative supportive relationship’.
Non-pharmacological management of chronic pain could include a ‘supervised group exercise programme’, acceptance and commitment therapy (ACT) or cognitive-behavioural therapy (CBT); or a course of acupuncture or dry needling, the guideline said.
The document acknowledged that the change in guidance ‘will involve a change of practice for some providers’ and that ‘to fully implement these recommendations for people with chronic pain, longer consultations or additional follow-up may be needed to discuss self-management and treatment options’.
NICE also recommended further research into the effectiveness of:
- pain management programmes;
- mindfulness therapy;
- CBT for insomnia related to pain; and
- gabapentinoids and local anaesthetics for complex regional pain syndrome.
The updated guidance follows Public Health England’s landmark review into prescription drug addiction, published last year, which concluded that one in four adults – over 11m adults in England – received a prescription for antidepressants, opioids, gabapentinoids, benzodiazepines or z-drugs in the previous year.
Nick Kosky, chair of the guideline committee and consultant psychiatrist at Dorset HealthCare NHS University Foundation Trust said: ‘Understandably, people with chronic pain expect a clear diagnosis and effective treatment. But its complexity and the fact GPs and specialists alike find chronic pain very challenging to manage, means this is often not possible.
‘This mismatch between patient expectations and treatment outcomes can affect the relationship between healthcare professionals and patients, a possible consequence of which is the prescribing of ineffective but harmful drugs.’
Paul Chrisp, director of the Centre for Guidelines at NICE, said the guideline highlighted the ‘fundamental importance of good communication’ with patients who suffer from chronic pain.
He added: ‘Importantly the draft guideline also acknowledges the need for further research across the range of possible treatment options, reflecting both the lack of evidence in this area and the need to provide further choice for people with the condition.’
But RCGP chair Professor Martin Marshall said that a ‘lack of access’ to alternative interventions must be addressed in order for them to benefit patients with chronic pain.
He said: ‘As such these new guidelines, which focus on alternative therapies, have the potential to be beneficial for patients – but they will need to be guaranteed appropriate access to them.
‘GPs are open to alternatives, as long as there is evidence of their benefit and effectiveness, and already do explore treatments for chronic pain, such as referrals to psychological therapies or pain management clinics, but currently access is patchy at community level across the country.’
He added that although GPs are ‘aware’ of the risks of prescribing pain medication and discuss this with patients, it is sometimes ‘the only thing that brings relief’.
And Professor Azeem Majeed, professor of primary care at Imperial College London told Pulse that GPs need ‘better options’ for managing patients with chronic pain.
He said: ‘The lack of services means that pharmacological interventions are sometimes the only option that is readily available to doctors.’
Other factors that are ‘largely outside the control of primary care teams’ must also be addressed for progress to be made, he added.
He said: ‘We need specialist pain clinics to be more cautious about prescribing these drugs as they are often started in secondary care.
‘[And] chronic pain also has strong social / psychological components and is compounded by other problems such as anxiety, stress, poor housing and difficult life circumstances. These also need to be addressed.’
Dr Farah Jameel, BMA GP Committee executive team clinical and prescribing lead, told Pulse the draft guidelines have been ‘a long time coming’.
She said: ‘GPs will often be the sole clinician managing the care of a patient with chronic pain, and we have been pushing for better clinical guidance around the use of these drugs.
‘We will be responding formally in due course, but it’s likely that final guidance should take into account the current backlog of elective operations postponed during the pandemic, and that these patients will need to be able to access appropriate pain management services to manage their symptoms ahead of procedures.’
Dr Jameel reiterated that the clinical guidance ‘must be backed with the commissioning of services’ to provide ‘effective alternatives’ to medication for pain management.
NICE draft chronic pain recommendations
1.1 Assessing all types of chronic pain
When assessing and managing any type of chronic pain, follow the recommendations in the NICE guideline on patient experience in adult NHS services
Recognise that chronic pain can cause distress. Foster a collaborative supportive relationship.
1.1.2 Ask the person to describe how pain affects their life, and how their life may affect their pain.
1.1.3 Ask the person about their understanding and acceptance of their condition, and that of their family, carers and significant others.
1.1.4 During discussions with the person and their family or carers (as appropriate), acknowledge the fact that the pain may not improve or may get worse.
1.1.5 Develop a care plan with the person with chronic pain. Explore their priorities, strengths, preferences, interests and abilities to inform the plan.
1.1.6 Discuss the possible benefits, risks and uncertainties of all management options for the person’s condition when first developing the care plan and at all stages of care.
1.1.7 Provide advice and information relevant to the person’s individual preferences, at all stages of care, to help them make decisions about managing their condition.
1.1.8 When communicating negative or normal test results, be sensitive to the risk of invalidating the person’s experience of pain.
1.3 Managing chronic primary pain
Non-pharmacological management of chronic primary pain
Exercise for chronic primary pain
1.3.1 Offer a supervised group exercise programme (for example, cardiovascular, mind–body, strength, or a combination of approaches) to people aged 16 years and over to manage chronic primary pain. Take people’s specific needs, preferences and abilities into account.
1.3.2 Encourage people with chronic primary pain to carry on with their exercise for longer-term general health benefits (also see NICE guidelines on physical activity and behaviour change: individual approaches).
Psychological therapy for chronic primary pain
1.3.3 Consider acceptance and commitment therapy (ACT) or cognitive– behavioural therapy (CBT) for pain for people aged 16 years and over with chronic primary pain.
1.3.4 Do not offer biofeedback to people aged 16 years and over to manage chronic primary pain.
Acupuncture for chronic primary pain
1.3.5 Consider a 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 (or lower) healthcare professional, 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).
Electrical physical modalities for chronic primary pain
1.3.6 Do not offer any of the following to people aged 16 years and over to manage chronic primary pain:
• interferential therapy
Manual therapy for chronic primary pain
1.3.7 Be aware that there was not enough evidence on manual therapy for chronic primary pain, so the committee made a recommendation for research.
Pharmacological management of chronic primary pain
1.3.8 Consider an antidepressant, either duloxetine, fluoxetine, paroxetine, citalopram, sertraline or amitriptyline, for people aged 16 years and over to manage chronic primary pain, after a full discussion of the benefits and risks. Note that this is an off-label use of these antidepressants.
1.3.9 For recommendations on reviewing treatments, see the NICE guidelines on medicines optimisation and medicines adherence.
1.3.10 For recommendations on stopping or reducing antidepressants , see the NICE guideline on depression in adults.
1.3.11 Do not offer any of the following, by any route, to people aged 16 years and over to manage chronic primary pain:
• non-steroidal anti-inflammatory drugs
• anti-epileptic drugs including gabapentinoids, unless gabapentinoids are offered as part of a clinical trial for complex regional pain syndrome* (see research recommendations)
• local anaesthetics, by any route, unless as part of a clinical trial for complex regional pain syndrome (see research recommendations)
• local anaesthetic/corticosteroid combinations
1.3.12 If a person with chronic primary pain is already taking any of the medicines in recommendation 1.3.11, explain the risks of continuing.
1.3.13 If a shared decision is made to stop antidepressants, opioids, gabapentinoids or benzodiazepines, be aware of the problems associated with withdrawal.
1.3.14 For recommendations on cannabis-based medicinal products, including recommendations for research, see the NICE guideline on cannabis based medicinal products.
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