National Institute for Health and Clinical Excellence (NICE)
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NICE recommends range of effective treatments for people with chronic primary pain and calls on healthcare professionals to recognise and treat a person’s pain as valid and unique to them

People with chronic primary pain should be offered a range of treatments to help them manage their condition, NICE has said in its guideline on the assessment and management of chronic pain published today (7 April)

Dr Paul Chrisp, director of the Centre for Guidelines at NICE, said: “We want this guideline to make a positive difference to people with chronic pain, and their families and carers.

“It highlights that achieving an understanding of how pain is affecting a person’s life and those around them and knowing what is important to the person is the first step in developing an effective care and support plan that recognises and treats a person’s pain as valid and unique to them.”

Pain that lasts for more than 3 months is known as chronic or persistent pain. In the UK the prevalence of chronic pain is uncertain, but appears common, affecting perhaps one-third to one-half of the population. The prevalence of chronic primary pain is unknown but is estimated to be between 1 and 6% in England. 

Chronic pain that is caused by an underlying condition (for example, osteoarthritis, rheumatoid arthritis, ulcerative colitis, endometriosis) is known as chronic secondary pain. Where the cause of the pain is unclear it is called chronic primary pain. Although the NICE guideline covers the assessment and development of a care and support plan for all types of chronic pain, it focuses on treatments for chronic primary pain. Pain management as part of palliative care is not covered in the guideline.

The guideline emphasises the need for shared decision making, putting patients at the centre of their care, and fostering a collaborative, supportive relationship between patients and healthcare professionals. It highlights the importance of healthcare professionals gaining an understanding of how a person’s life affects their pain and how pain affects their life, including their work and leisure time, relationships with family and friends, and sleep.

The guideline recommends that a care and support plan should be developed based on the effects of pain on day-to-day activities, as well as a person’s preferences, abilities and goals. It also highlights the importance of being honest with the person about the uncertainty of the prognosis.

The guideline makes recommendations for treatments that have been shown to be effective in managing chronic primary pain. These include exercise programmes and the psychological therapies CBT and acceptance and commitment therapy (ACT). Acupuncture is also recommended as an option.

People with chronic primary pain should not be started on commonly used drugs including paracetamol, non-steroidal anti-inflammatory drugs, benzodiazepines or opioids. This is because 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 guideline does recommend that an antidepressant can be considered for people aged 18 years and over to manage chronic primary pain, after a full discussion of the benefits and harms. This is because the evidence shows antidepressants may help with quality of life, pain, sleep and psychological distress, even in the absence of a diagnosis of depression.

Dr Chrisp added: “This guideline is very clear in highlighting that, based on the evidence, for most people it’s unlikely that any drug treatments for chronic primary pain, other than antidepressants, provide an adequate balance between any benefits they might provide and the risks associated with them.

“But 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.”

Nick Kosky, a consultant psychiatrist at Dorset HealthCare NHS University Foundation Trust and chair of the guideline committee 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 guideline underlines the importance of appropriate assessment, careful drug choice, exercise programmes, psychological therapies, and consideration of acupuncture in improving the experience and outcomes of care for people with chronic pain.”

Lucy Ryan, a patient representative on the guideline committee, said: “This guideline will provide more consistency in treatment and support on the NHS for people experiencing chronic pain. I am pleased that it has highlighted the potential risks of some of the drugs used to treat chronic primary pain as I feel people are sometimes not made aware of these. I am also pleased that the guideline provides alternative treatment choices and that gaps in research have been identified. I hope that this will mean future guidelines will incorporate many more options for people managing chronic primary pain following further research. Everyone with chronic pain experiences pain differently so I feel the more options available to help people effectively manage their pain the better.”

NICE is also producing guidelines on shared decision making and the safe prescribing and withdrawal management of medicines associated with dependence or withdrawal symptoms; these are expected to be published in June 2021 and November 2021 respectively.

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