Paracetamol, NSAIDs, benzodiazepines and opioids should not be offered to people with chronic primary pain because there is little evidence that they make any difference to people’s quality of life, pain or psychological distress, according to NICE.
The draft guidance, which is NICE's first ever guideline on the assessment and management of chronic pain, also says that antiepileptic drugs (including gabapentinoids), local anaesthetics, ketamine, corticosteroids and antipsychotics should not be offered to people to manage chronic primary pain.
Instead, patients should be offered supervised group exercise programmes, certain types of psychological therapy (eg, cognitive behavioural therapy [CBT]), or acupuncture. Some antidepressants (duloxetine, fluoxetine, paroxetine, citalopram, sertraline or amitriptyline) can also be considered, NICE says, although their use in this context is off-label.
The guideline committee highlighted evidence that CBT improved quality of life for people with chronic pain, while exercise reduced pain and improved quality of life compared with usual care. The committee also concluded that acupuncture reduced pain and improved quality of life in the short-term; however, to ensure cost-effectiveness of this intervention, NICE said it should only be provided in a community setting, by a band 7 or lower health professional, and involve no more than 5 hours of that person's time.
For patients already taking antidepressants, opioids, gabapentinoids or benzodiazepines, GPs should explain the risks of continuing to take the drugs. If a shared decision is made to stop treatment, prescribers should be aware of the problems associated with withdrawal.
The guideline emphasises the importance of 'putting the patient at the centre of their care', and of fostering a 'collaborative, supportive relationship' between the patient and healthcare professional. It also highlights the role of good communication and its impact on the experience of care for people with chronic pain.
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 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.
'This guideline, by fostering a clearer understanding of the evidence for the effectiveness of chronic pain treatments, will help to improve the confidence of healthcare professionals in their conversations with patients. In doing so it will help them better manage both their own and their patient’s expectations.'
The guideline is open for public consultation until 14 September.