NICE guidelines on management of chronic pain: exercise but not opiods

Simon Collins, HIV i-Base

On 7 April 2021, the National Institute for Clinical Excellence (NICE) issued long-awaited guidelines for the management of chronic pain in adults aged 16 and older. The document and supporting papers cover both primary pain (without a clear cause) and secondary pain (linked to anther illness), estimated to affect between 1 to 6% of people living in England. [1]

The guidelines are written for health workers, commissioners and people affected by chronic pain. They are apparently not aimed to be proscriptive, but to offer guidance to improve overall care. They are also to be used together with other NICE guidelines on condition with chronic pain, including guidelines on headaches, low back pain and sciatica, rheumatoid arthritis, osteoarthritis,spondyloarthritis, endometriosis, neuropathic pain and irritable bowel syndrome.

The guidelines are framed around concern for individualised care that itself is centred on the experiences and involvement of the individual and their preferences.

Each section of the 36-page guidelines are supported by much longer and more extensive evidence reviews. For example, the preferred recommendation for exercise runs is almost 600 pages to review 23 studies that reduced pain (and 22 that improved quality of life), but then didn’t recommended a particular type of exercise.

The main interventions that are recommended (some just considered) include:

Exercise.
Psychological therapies: CBT and acceptance and commitment therapy (ACT) are NOT recommended but can be considered).
Acupuncture can be considered – but only a single course (maximum five hours), even if effective.
Antidepressants: amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline. Only if >18 years old).

Many commonly used drugs are NOT recommended because of too little evidence of benefit and a concern they might cause harm. These include:

Paracetamol.
Non-steroidal anti-inflammatory drugs (NSAIDs).
Benzodiazepines.
Opioids.

Although the minimal evidence for relaxation therapy, mindfulness or psychotherapy suggested there may be some benefit the guidelines only recommended further research.

The guideline panel certainly took their evidence review seriously. Even though ‘talking to people about their pain’ was not supported by evidence, patient education has still been included as a recommendation – on the basis that there is ‘a possible benefit and there was no evidence of harm’. (Really).

Although short-term acupuncture (three months) is recommended, based on the 200-page evidence review from 27 studies, subsequent courses are not supported, even if the treatment worked.

Other areas highlighted for further research in the management of primary pain, due to lack of evidence, include:

Mindfulness.
Cognitive behavioural therapy (CBT) for insomnia. (Both following a 460-page evidence review).
Manual therapy, including including physiotherapy, occupational therapy, osteopathy, chiropractice and massage. (Following a 150-page evidence review).
Repeat courses of acupuncture. (see above)
Other drug treatments, including gabapentinoids and topical treatment. (Following a 350-page evidence review).
Everything else: psychotherapy, relaxation therapy, laser therapy and magnetic stimulation

comment

The guidelines are the result of a staggering amount of work, but they are unlikely to be received well by many people hoping for more support. More seriously, some recommendations might reduce quality of life by withdrawing options that are currently working in some individuals.

HIV is not specifically mentioned.

Also, while the guidelines say they are advisory and not proscriptive, auditable health targets are commonly linked to the recommendations. These by definition limit the degree of patient access and choice, even when individual exceptions are allowed. Also, as gatekeepers to care, the outcomes from person-centred care are still largely steered and defined by doctors and other health professionals.

Although NICE is producing two new guidelines: on shared decision making and on prescribing and withdrawal of drugs associated with dependence, these are not expected until June 2021 and November 2021 respectively.

The decision to restrict acupuncture that is effectively helping to a single five-hour course for a chronic condition is really not helpful. People who are not helped will not want repeated sessions, those it helps should not be blocked due to lack of evidence of repeated benefit.

An easier and more acceptable outcome would be to recommend continued access for people who already benefit, and to encourage researchers to work with this group to collect further evidence on the effectiveness for additional courses.

References

NICE press release. NICE recommends range of effective treatments for people with chronic primary pain and calls on healthcare professionals to recognise and treat a person’s pain as valid and unique to them, (7 April 2021).
https://www.nice.org.uk/news/article/nice-recommends-range-of-effective-treatments-for-people-with-chronic-primary-pain-and-calls-on-healthcare-professionals-to-recognise-and-treat-a-person-s-pain-as-valid-and-unique-to-them
NICE guidelines. Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE guideline [NG193]. (07 April 2021)
https://www.nice.org.uk/guidance/NG193 (download page).
https://www.nice.org.uk/guidance/ng193/resources/chronic-pain-primary-and-secondary-in-over-16s-assessment-of-all-chronic-pain-and-management-of-chronic-primary-pain-pdf-66142080468421 (PDF)

This report was first published on 9 April 2021.