In April 2021, the National Institute for health and Care Excellence (Nice) published a new guideline: Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain.
This summary should be used in conjunction with Nice guidelines for other chronic pain conditions including headaches, low back pain and sciatica, rheumatoid arthritis, osteoarthritis, spondyloarthritis, endometriosis, neuropathic pain and irritable bowel syndrome.
It may be useful to print this summary as a resource for your pharmacy team – PDF available here.
Chronic pain, which is defined as pain lasting for more than three months, can either be:
- Primary (no clear underlying condition/disproportional pain to any observable injury or disease)
- Secondary (caused by an underlying condition) in nature.
Providing advice and information
When communicating with people living with chronic primary pain, pharmacy teams should be mindful that:
- Symptoms may fluctuate over time and that the patient may have flare-ups
- There is a possibility that a reason for the pain or flare-up may not have been identified
- There is a possibility that the pain may not improve or it may get worse and need ongoing re-evaluation and management
- There can be improvements in quality of life even if the pain remains unchanged.
It is important to not invalidate the experiences of individuals who report negative or normal test results in the assessment of their pain and potential underlying causes. Pharmacy teams are well placed to ask patients how chronic pain affects their everyday life and their understanding of the condition and possible treatment outcomes.
Individuals should receive a support plan that incorporates the following elements:
- their priorities, abilities and goals
- what they are already doing that is helpful
- their preferred approach to treatment and balance of treatments for multiple conditions
- any support needed for young adults (aged 16 to 25) to continue with their education or training, if appropriate.
Pharmacy teams should encourage those who report a flare-up of symptoms to seek a reassessment of their symptoms. Additional steps include:
- reviewing the individual’s support plan
- investigating and managing new symptoms
- discussing the cause of the flare-up.
Recommendations for the management of chronic primary pain
Step 1: Non-pharmacological management
It is important that the patient’s needs, preferences and abilities are considered prior to therapy. Furthermore, treatment should be offered on a case-by-case basis, using a patient-centred approach, with additional eligibility criteria for management options discussed in the full guideline. Providing patients with advice and support can help them to make decisions about managing their condition and self-management.
The following non-pharmacological therapies should be offered to individuals that present with chronic primary pain:
- supervised group exercise programmes – all people with chronic primary pain should be encouraged to remain physically active
- psychological therapy including acceptance and commitment therapy (ACT) or cognitive behavioural therapy (CBT)
- a single course of acupuncture or dry needling.
Step 2: Pharmacological Management
- Offer treatment with an antidepressant* such as amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline, for people aged 18 years and over.
- Specialist advice should be sought when considering antidepressant therapy for people aged 16 to 17 years.
- Discuss with the individual that antidepressant therapy may help with quality of life, pain, sleep and psychological distress even in the absence of depression.
*Note that this is off-label prescribing. Doses for selective-serotonin reuptake inhibtors and serotonin-norepinephrine reuptake inhibitors should be in line with British National Formulary recommendations for depression. Amitriptyline should be initiated at the lowest possible dose and titrated to no more than 100mg per day (evidence indicated benefit at very low doses of 5mg per day).
Step 3: Pharmacological Review
- The following groups of medicines should not be initiated in people aged over 16 for the management of chronic primary pain:
- antiepileptic drugs including gabapentinoids*
- antipsychotic drugs
- corticosteroid trigger point injections
- ketamine, anaesthetics (topical or intravenous)*
- local anaesthetic/corticosteroid combination trigger point injections
- non-steroidal anti-inflammatory drugs
- If a person with chronic primary pain already uses one of the medicines listed above, a prescribing review should take place as part of shared decision making, with emphasis on the following:
- The lack of evidence for these medicines in managing chronic primary pain and
- Agreeing a shared plan for continuing safely if they report benefit at a safe dose and few harms or
- Explaining the risks of continuing if they report little benefit or significant harm and encourage and support them to reduce and stop the medicine if possible.
*Unless offered as part of a clinical trial for complex regional pain syndrome.
National Institute for health and Care Excellence (2021) Nice guideline NG193: Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain
This summary is intended as a quick guide resource for pharmacy teams. For more detailed information, please see the full guideline.