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Chronic pain management

Aspirin, paracetamol and ibuprofen should not be prescribed for chronic pain syndromes, NICE draft guidance says

The National Institute for Health and Care Excellence draft guidance says exercise, psychological therapies and acupuncture should be offered instead of common analgesics.

woman taking aspirin ss 19

Source: Shutterstock.com

The draft guidance concluded that there was little evidence that many of the commonly prescribed drugs made a difference to patients’ quality of life

Common pain medicines — such as paracetamol, non-steroidal anti-inflammatory drugs including aspirin and ibuprofen, benzodiazepines, and opioids — should not be offered to patients with chronic primary pain, according to National Institute for Health and Care Excellence (NICE) draft guidance

But exercise, psychological therapies such as cognitive behavioural therapy (CBT), and acupuncture should be offered, says the draft guidance, published on 4 August 2020.

The guidance, on managing chronic pain in patients aged over 16, concluded that there was little evidence that many of the commonly prescribed drugs made a difference to the patient’s quality of life — but that there was evidence they can lead to problems, including the risk of addiction.

It also recommends avoiding the use of antiepileptic drugs, including gabapentinoids, again because of “limited evidence” that they offer relief. But it says that certain antidepressants, such as commonly prescribed selective serotonin reuptake inhibitors, can be prescribed off-label after patient and prescriber have had a “full discussion of the benefits and risks”.

The guidance recommends a range of non-pharmacological interventions for chronic primary pain management, including group exercise; psychological therapies, including acceptance and commitment therapy and CBT; and acupuncture. The latter, it said, should be delivered by a band 7 (or lower) healthcare professional.

Chronic primary pain is a condition that persists for longer than three months and is associated with significant emotional distress or functional disability and that cannot be explained by another chronic condition. This includes conditions such as fibromyalgia, complex regional pain syndrome, chronic migraine, irritable bowel syndrome and non-specific low-back pain.

Wing Tang, head of professional standards at the Royal Pharmaceutical Society, said: “The recommendations presented in this draft guidance should be looked at carefully and we will consider the underlying evidence.

“Pharmacists are often the first port of call in helping those with chronic and acute pain and will always want to provide the best possible advice, based upon the latest evidence, to support people to manage pain.”

Martin Marshall, chair of the Royal College of General Practitioners, said there was currently “a lack of access to some of the evidence-based interventions” recommended in the guidance.

“Most patients in pain do not want to take medication long-term, and GPs do not want this either, but sometimes medication has been the only thing that brings relief,” he said.

Marshall added that the recommendations for “alternative therapies” in the guidance have the potential to benefit patients, “but they will need to be guaranteed appropriate access to them”.

“We should also be mindful not to disregard some medications completely, as a lack of evidence may be due to a lack of high-quality research, particularly for older drugs, such as paracetamol.”

The draft guidance is open for consultation until 14 September 2020. 

Correction: The headline of this article was changed on the 05 August 2020 to make clear that the treatment advice in this draft guideline on chronic pain relates to chronic primary pain, rather than all chronic pain, as the article later explains. 

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2020.20208239

Readers' comments (7)

  • You people completely speak out of your back sides, you obviously have no idea what its like to be in pain 24\7 like I am, unfortunately I have lots of different disabilities both physical and mental health ones, and it is pure Aging when you are in constant pain 24\7, unfortunately no pain killers now take away the pain I am in 24\7 since tramadol's were no longer able to be prescribed to me, antidepressants can take your life and also has very nasty seriously bad side affects, as well as are very dangerous if your single and taking them they can make you feel like a God and powerful as well as suicidal also, the only other thing that would seem to work is medicinal cannabis which is also non addictive, people like you idiots have already stopped disabled people like myself from being able to get paracetamol during the covid-19 epidemic who are agoraphobia, because we have NOT been able to get these from our GPS, many of us like myself struggled to get hold of paracetamol and when we could get it from chemists it was seriously expensive, in my case my carers were NOT even able to get these for me because my gp denied me from getting them on prescription, so I had to struggle with no pain relief which was absolutely agony, the solutions that you are talking about are totally stupid and ridiculous, if your in agony, NOTHING can stop the pain other than pain killers or death, this will end up with people in serious pain taking their own lives because of the pain that we are in because of total selfish stupid idiots like you, there is nothing worse than being in total pain 24\7 and the only thing that helps to at least reduce the pain is pain killers or possibly medicinal cannabis which is highly used in America but still not in Britain which is a complete joke, even as I'm writing this I'm in severe pain in my spine, and my legs, hands and head and have a bad headache also because of stress and anxiety etc that is going through at the moment, my many disabilities will NEVER get better, normally if you have 1 or 2 disabilities, you normally get more health problems over time which further increase the pain levels. As I say unfortunately for me now, there is NOTHING that takes all the pain away that I'm in since I can no longer get tramadol's on prescription, no matter what pain killers I take now, NOTHING takes the total pain away that I'm in.

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  • I have to agree with the person above. Only people that are not in chronic pain can suggest CBT etc. Absolute rubbish and dangerous to people like us. Would you like to live with Chronic pain 24/7 most people have no idea how debilitating it is. If my Tramadol is stopped I could not suffer the pain this would cause. I do NOT want to take any more of this drug but until an alternative is found eg find out my problem (nerve damage) and fix it I have no choice!!!

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  • Your banner headline is very misleading as it implies the NICE guidance referred to is for all chronic pain.
    It is actually for 'Chronic Primary Pain' only.
    This is a new definition for a group of previously poorly defined pain conditions.
    Most chronic pain patients suffer from nerve injury related pain (neuropathic pain), rheumatoid arthritis, cancer related pain, chronic low back pain and other conditions - which are not covered by this guidance for "'chronic primary pain' and where the pharmacological treatments may be useful or actually recommended.

    I suggest your banner headline is amended and a definition for 'chronic primary pain' included in your article to avoid the RPS spreading mis-leading information.

    Mark J. Field 
    AnalgesicInnovation.com

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  • Dear Mark, thank you for this feedback we have altered the headline to make this clear.

  • The worry is that these items might become POMs now. And then prescribing pharmacists will feel under pressure not to prescribe them (like not giving antibiotics to children with earaches). No more OTC cold-cures any more?

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  • Mindfulness is nonsense so CBT is a waste of time for those in pain, and needles? Not a chance!

    I suppose this idea comes from someone that hasn't had to put up with constant pain? Why are these idiots allowed to make up rules they know will cause problems?

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  • Antidepressants definitely help and I have never found them to be as terrible as others do. But they only help. Mobility being such an issue with chronic pain, it is unbelievably difficult to get out to exercise or visit alternative practitioners. OTC painkillers aren't brilliant but often they help one just get up and move. Here in Canada all therapists other than a doctor cost money and I don't know a lot people with disabili
    ties that have the funds.

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  • I have been a pharmacist for 36 years with a wide and fulfilling career experience. I am also a chronic pain sufferer. I have been reduced to a mere wreck of my former self due to this. The impact of this on moods is beyond the comprehension of those who sit on NICE panels. They consider evidence-based medicine only. Patients' experiences with pain are not evidence based, so are irrelevant to those pen pushers. I am a scientist by nature and have stong confidence in evidence-based medicine when it is practiced with patient factors as considerations.

    In my case I have to rely on paracetamol and codeine for pain and to find a happy medium with IBS (also mentioned in the draft guidelines), to avoid 8 or more bowel openings a day, urgency, discomfort, flatulence and ano-rectal fissures caused by bowel frequency. I use ibuprofen only occasionally to treat flares, quite successfully, I might add. Even though there is never a pain free period, I refuse to use more powerful medication. I rely on physical mobilisation and trying to keep a positive mental attitude. The pain has given way to depression, which is hard to write about here, but I wish to tell my story, so I will. I take the antidepressants mentioned in the guidelines, to get through the days, they may relieve pain to a degree (who knows), but I need to rely on the pain medication, despite my best effort to get by without.

    Paracetamol, codeine and ibuprofen have been around for a very long time. They were around long before evidence-based medicine was in its infancy. Big pharma has no gains to make from sponsoring drug trials with these, to produce definitive evidence of benefit (or not), so NICE relies on "available" evidence base (or lack thereof). This draft guideline is flawed to the greatest extent as it does not consider real patient factors, like mine.

    As am employee pharmacist, I do not have the luxury of devoting time to attend psychological therapies, I have tried acupuncture without success. I do not even have time to practice mindfulness due to the amount of time I am at work or traveling to and from work. How would the NICE panel square, time away from work to manage my pain by attending these alternative therapies, with my employers?

    Time for NICE panels to wake up and smell the coffee.

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