Contributed by: Anuolu Bank-Oni, PharmD, CDE, BCGP
As defined by the National Institute for Health and Care Excellence (NICE) guideline, chronic primary pain is present in one or more parts of the body and lasts for more than three months. Chronic pain negatively impacts the physical, emotional, and social well-being of the patient. The economy also shares in the burden, as chronic pain increases healthcare costs while reducing work productivity.
Treating chronic pain can be challenging because each patient requires a tailored care plan. Finding the balance between the benefits and risks of available treatment options requires the collaboration of the physician and the patient. The physician should ensure the patient actively participates in creating their treatment plan.
NICE recently published draft guidance on the assessment and management of chronic pain in patients aged 16 years and older.
Non-pharmacological management of chronic primary pain
Supervised group exercise, acceptance and commitment therapy (ACT) or cognitive behavioural therapy (CBT) are recommended for patients with chronic primary pain. Acupuncture or dry needling may be considered but more research is required to determine long-term benefits.
The guideline does not recommend biofeedback or electrical therapies (TENS, ultrasound and interferential therapy). Manual therapy requires additional research, as there is insufficient evidence to issue a recommendation regarding its use.
Pharmacological management of chronic primary pain
The guideline recommends against the use of most of the currently prescribed pain medications, by any route, to patients aged 16 years and older to manage chronic primary pain. These include:
- antiepileptics including gabapentinoids, (except when gabapentinoids are prescribed as part of a clinical trial for complex regional pain syndrome)
- antipsychotics
- benzodiazepines
- corticosteroids
- ketamine
- local anaesthetics (except as part of a clinical trial for complex regional pain syndrome)
- local anaesthetic/corticosteroid combinations
- non-steroidal anti-inflammatory drugs (NSAIDs)
- opioids
- paracetamol
According to NICE, studies showed that these medications have limited/no benefit in managing chronic primary pain. Conversely, there was an increased risk of addiction and misuse with opioids, benzodiazepines, gabapentinoids. Other adverse effects observed include gastrointestinal bleeds with NSAID, and impaired psychological and physical functioning with benzodiazepines.
Instead, antidepressants (duloxetine, fluoxetine, paroxetine, citalopram, sertraline or amitriptyline) are listed as therapeutic options, recognising this would be off-label use. Benefits and risks should be discussed with the patient.
Studies indicate that antidepressants improve quality of life, pain and psychological distress compared with placebo. However, most of the evidence available involved women with fibromyalgia.
It is important to remember that patients who discontinue antidepressants, opioids, gabapentinoids or benzodiazepines may experience withdrawal symptoms. NICE is developing a guideline on withdrawal management.
Patients who are currently on any of these medications should be educated on the most recent available evidence. Physicians should discuss the risks associated with continuing the medications and possible alternatives.
Conclusion
Chronic primary pain affects a significant portion of the population and poses a burden to patients and the community. Long term, deprescribing will reduce the risk of adverse effects and promote the appropriate use of medications. More research is required to determine the most appropriate treatment options for chronic primary pain.
Reference
- Chronic pain: NICE guideline DRAFT (August 2020). [online] Available at: <https://www.nice.org.uk/guidance/gid-ng10069/documents/draft-guideline> [Accessed 11 August 2020]