In the wake of continued concerns about the growing opioid crisis in the UK, NICE (National Institute for Health and Clinical Excellence) has published a draft guideline for consultation for the assessment and management of chronic pain in the over 16s. The consultation on this new clinical guideline, which was commissioned in May 2017 and closes on 14th September 2020. Comments from stakeholder organisations are invited but individuals are not able to comment.
NICE is an agency of the National Health Service charged with promoting clinical excellence in NHS service providers in England and Wales, by developing guidance and recommendations on the effectiveness of treatments and medical procedures.
NICE guidelines are evidence-based recommendations that set out the care and services suitable for most people with a specific condition or need, and people in particular circumstances or settings.
The draft guideline on chronic pain includes a number of recommendations on pharmaceutical and non-pharmaceutical management of chronic pain, with recommendations for research on some of the non-pharmaceutical options.
However, the guideline is emphatic in its recommendation that certain pharmaceuticals should not be prescribed to managed chronic primary, with opioids at the top of the list. The document states:
“Do not offer any of the following, by any route, to people aged 16 years and over to manage chronic primary pain;
non-steroidal anti-inflammatory drugs
anti-epileptic drugs including gabapentinoidsParacetamol
The guidance suggests that:
“The lack of evidence for effectiveness of opioids, along with evidence of long-term harm, persuaded the committee to recommend against opioid use for people with chronic primary pain.
“Although there were limitations, evidence from non-randomised studies on the long-term use (more than six months) of opioids for chronic pain suggested an increased risk of dependence.
The committee also agreed that even short-term use of opioids could be harmful for a chronic condition.
The report has been particularly welcomed by drug addiction treatment experts such as UKAT. Managing Director, Eytan Alexander says:
“Finally, it is written in black and white the dangers and addictive nature that prescribing opioids and other ‘pain relief’ drugs can have on patients”
“Prescription drug addiction is as real as a Heroin addiction, but in this case, the addict gets their drugs from their GP rather than a dealer, to ‘treat’ their pain. We’re pleased to hear that today, the advice is that this should no longer be an option. GP’s need to be supported and resourced well enough so that they can spend a longer amount of time with their patients in order to provide a more holistic, safer treatment plan for chronic pain. One that doesn’t lead to addiction.”
Naturally, GPs will need to carefully consider how they manage patients who have been previously prescribed any of these addictive medications.
The clinical pharmacists based at most GP surgeries will be able to provide appropriate advice and support for those patients.
The University of East Anglia’s opioid-reduction expert Dr Debi Bhattacharya has launched a toolkit to help GPs reduce the amount of opioids they prescribe.
In June 2019, the NHS published a YouTube Video to help prescribers support patients to reduce their medication for chronic pain and offers advice on training materials that are available.
Hopefully, social prescribing will increasingly be embraced by GP surgeries for a number of conditions including chronic pain. The NICE guideline suggests the following as some of the non-pharmaceutical interventions available as alternatives to the addictive medications currently prescribed:
1. Pain management programmes
These have been used effectively in the NHS for many years and involve talks and practical sessions where people learn about pain and ways to try and control and limit pain and how to exercise safely and build up activity levels.
As the programmes vary from area to area and evidence on the effectiveness is inconsistent, the guideline has made a recommendation for research.
2. Exercise for chronic pain
Supervised group exercise programmes, taking into account people’s specific needs, preferences, and abilities into account. The exercises may include cardiovascular, mind–body, strength, or a combination of approaches.
People already exercising for longer-term health benefits should be encouraged to carry on the regime, adapting as necessary. [Healthy Life Essex recommends using fully qualified professionals such as CHEK practitioners with enhanced skills and knowledge and a more holistic approach to exercise.]
3. Psychological therapies such as ACT and CBT
Acceptance and Commitment Therapy (ACT) and Cognitive Behaviour Therapy (CBT) are both behaviour-based therapies. CBT works by helping identify and change negative or destructive thoughts whereas ACT holds that pain and discomfort are a fact of life – something we must get comfortable with if we wish to live a happy, fulfilled life. ACT encourages you to accept all thoughts rather than trying to change them – both the good and the bad.
Biofeedback is not recommended to people aged 16years and over to manage chronic primary pain.
4. Acupuncture or dry needling
A course of acupuncture or dry needling is recommended provided the course is delivered in a community setting by a healthcare professional with a maximum of 5 hours of professional time.
5. Manual therapy
The guideline states that there is insufficient evidence on manual therapy (as provided by a physiotherapist, for example) and made a recommendation for research.
Medication image by Gordon Johnson from Pixabay
Exercise image by StockSnap from Pixabay