The National Institute for Health and Care Excellence (NICE) in the UK released a guideline for the assessment and management of all types of chronic pain (primary, secondary, or both) in persons aged 16 years and older. The guideline, which was developed in partnership with the Royal College of Physicians, is aimed at health care professionals, commissioners and providers of services; people with chronic primary or secondary pain; and the families and caretakers of people with chronic pain.
It is recommended that the guideline be used alongside NICE guidelines for other chronic pain conditions.
Assessing All Types of Chronic Pain
Because pain is always influenced by social and emotional factors, expectations and belief, mental health, and biology, the contributing factors should always be considered when assessing pain. Specifically, the guideline provides recommendations in 6 areas chosen to help inform person-centered assessment of the cause and effect of pain, agreement on possible management strategies, and ultimately a care and support plan.
The 6 areas are as follows:
- Using a person-centered assessment
- Thinking about possible causes
- Talking about pain, including how it affects life and how life affects pain
- Providing advice and information
- Developing a care and support plan
- Managing flare-ups
The recommendations focus on the importance of health care professionals understanding how pain affects patients’ lives and how their lifestyles and circumstances affect pain. This requires that patients’ socioeconomic, cultural, and ethnic background and faith group be considered.
Care plans should also be based on the effect of pain on routine daily activities in light of people’s individual preferences, abilities, and goals. Keep in mind that it is impossible to predict future outcomes, and pain can fluctuate overtime.
The guideline also emphasizes the importance of communication and shared decision-making. However, the committee acknowledged this is an area that needs to be addressed. Chronic pain is a complex disorder, and not every treatment will be effective for, or well tolerated by, each patient.
Honesty regarding prognosis is important and valued by patients. To fully implement the recommendations regarding assessment, longer consultations or more follow-ups may be required.
Managing Chronic Primary Pain
Recommendations regarding nonpharmacologic management of chronic pain in ages 16 and older and specific considerations for each are as follows:
- Exercise programs and physical activity. Offer supervised group programs while taking into consideration patients’ specific needs, abilities, and preferences, and encourage them to remain active for general and long-term health benefits.
- Psychological therapy. Consider acceptance and commitment therapy or cognitive behavioral therapy delivered by health care professionals with appropriate training. Do not offer biofeedback to ages 16 and older.
- Acupuncture. Consider a single course of acupuncture or dry needling in either a traditional Chinese or Western system, but only if the course is delivered in a community setting by a band 7 equivalent or lower professional with appropriate training, is no more than 5 hours of health care professional time or is delivered by another healthcare professional with appropriate training and/or in another setting for equivalent or lower cost.
- Electrical physical modalities. Do not offer transcutaneous electrical nerve stimulation (TENS), ultrasound, or interferential therapy for pain management because there is no supporting evidence of benefits.
For the pharmacologic management of chronic pain, several recommendations were made. For people aged 18 years and older, consider using the antidepressants amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine, or sertraline. These should be considered only after a full discussion of harms and benefits and knowing that as of April 2021, this is an off-label use.
The guideline recommends that the following not be initiated in patients 16 and older unless it is for a clinical trial: antiepileptic drugs including gabapentinoids, antipsychotic drugs, benzodiazepines, corticosteroid trigger-point injections, ketamine, local anesthetics, trigger-point injections of local anesthetic combined with corticosteroids, nonsteroidal anti-inflammatory drugs, opioids, or acetaminophen.
If patients are already taking these medications, review the prescriptions in the context of shared decision-making and explain the lack of evidence and risks while agreeing to a shared plan for continued safe use if patients report benefits. Discuss potential withdrawal problems if the shared decision to stop antidepressants, opioids, gabapentinoids, or benzodiazepines is made.
Recommendations for further research include psychological therapies, such as mindfulness and cognitive behavioral therapy for insomnia and pain, and for manual therapies, acupuncture; and the use of gabapentinoids and local anesthetics for complex regional pain syndrome. Factors that act as barriers to successful pain management, social interventions, psychotherapy, relaxation therapy, laser therapy, and transcranial magnetic stimulation are all topics warranting further research.
Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. National Institute for Health and Care Excellence. Published online April 7, 2021. www.nice.org.uk/guidance/ng193.