Chronic pain sufferers should take exercise, not analgesics, says Nice
Medicines watchdog recommends physical and psychological therapies when treating pain with no known cause.
People suffering from chronic pain that has no known cause should not be prescribed painkillers, the medicines watchdog has announced, recommending such patients be offered exercise, talking therapies and acupuncture instead.
In a major change of pain treatment policy, the National Institute for health and Care Excellence (Nice) say that in future, doctors should advise sufferers to use physical and psychological therapies rather than analgesics to manage their pain. Medical teams can also consider prescribing antidepressants, the government health advisers suggest.
Nice’s new guidance potentially affects the way many hundreds of thousands of people in England and Wales tackle their condition because between 1% and 6% of the population of England is estimated to have chronic primary pain.
There is “little or no evidence” that treating the condition with painkillers makes any difference to the person’s quality of life, or the pain they suffer or their psychological distress, according to its new guidelines on the assessment and management of chronic pain.
Pain caused by a known underlying health condition such as osteoarthritis, rheumatoid arthritis, ulcerative colitis or endometriosis is known as chronic secondary pain. However, pain with no identified cause that has persisted for at least three months is known as chronic primary pain.
Nice recommends that doctors draw up a care and support plan with patients about how to manage their pain based on how badly it is affecting their day-to-day life, what activities they feel they can undertake and honesty “about the uncertainty of the prognosis”.
The plan should include “interventions that have been shown to be effective in managing chronic primary pain. These include exercise programmes and the psychological treatments cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT).
“Acupuncture is also recommended as an option, provided it is delivered within certain clearly defined parameters,” Nice says.
The antidepressants amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline can also be used, it adds.
Sufferers should not be started on commonly used medications such as paracetamol, non-steroidal anti-inflammatory drugs, benzodiazepines or opioids, which poses risks including addiction, the watchdog says. Dr Paul Chrisp, director of Nice’s centre for guidelines, said: “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.”
The Royal College of GPs backed the shift away from painkillers but cautioned that patients’ access to the new forms of treatment being recommended was variable.
Prof Martin Marshall, the college’s chair, said: “Pain can cause untold misery for patients and their families. Chronic primary pain… can be challenging to manage in general practice, and the college has been calling for guidelines to address this for some time.
“We 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.”
Lucy Ryan, a patient representative who helped Nice draw up the new guidelines, welcomed its acknowledgement of the risks that a regime of tablets for chronic primary pain can involve because patients are sometimes not told about those.
“Everyone with chronic pain experiences pain differently, so I feel the more options available to help people effectively manage their pain, the better,” she added.