Nobody knows better than GPs the huge problem of chronic pain and the secondary dependency on prescription drugs. We have been aware of this issue for a long time and evidence has been accumulating year after year of the inefficacy and potential harm of commonly used treatments such as opioids, including addiction. And yet, faced with suffering patients in pain and with limited other options to offer, we have kept on prescribing…
NICE published the draft version of their long-awaited guideline on chronic pain Chronic Pain 2020, NG10069 this week. The guideline has hit the headlines with the recommendation that commonly used drugs such as paracetamol, ibuprofen, opioids and gabapentinoids for chronic primary pain cause more harm than good and should not be used. This conclusion is based on the lack of evidence for efficacy and the evidence of longer-term harm. The guideline advises that we should instead consider non-pharmacological approaches such as psychological therapies, supervised exercise programmes and acupuncture. If drugs are to be prescribed, then we should consider antidepressants in preference to analgesics. It is important to realise that the guideline refers to chronic primary pain (defined as a pain that cannot be accounted for by another specific diagnosis, which persists for > 3 months and is accompanied by significant emotional distress or functional impairment) and is therefore separate to other guidelines on chronic secondary pain due to specific conditions e.g. low back pain and sciatica, neuropathic pain, endometriosis etc.
Many GPs and prescribers may criticise NICE for an 'ivory tower' approach which seems far removed from the messy reality of practice and that does not take into account the complexity of clinical care and the lack of access to non-pharmacological treatments. Others however may praise them for an evidence-based approach and a candid acknowledgement that the drugs don’t work, thereby drawing a line in the sand and henceforth making it easier for GPs not to prescribe analgesics for chronic pain.
Personally, I welcome the guideline and think NICE should be congratulated on adopting a bold stand, which is evidence-based and honest in its conclusions. It should trigger a paradigm shift in care, which starts with open and frank communication with patients about the lack of benefit and potential for harm of many drugs that we have been prescribing for years. It can empower us to open up a more truthful dialogue with patients about the limitations and dangers of prescribing and thus enable evidence-informed, shared decision making. Many social, psychological and biological factors contribute to a patient’s unique experience of chronic pain and a consultation focussed on prescribing diverts attention from these; by removing prescribing from the agenda, we can adopt a more holistic and individualised approach to patient care. However, if we are to be honest that the drugs don’t work, we also need to be honest that GPs have both limited time to give to patients and little access to these alternative therapies.
As every GP knows, managing patient expectations is vital to improve outcomes and hopefully this guideline will make it easier to do so. But if the NHS is serious about tackling chronic pain and dependency on prescription drugs, it needs to be serious about providing extra support for us and our patients. We need greater access to non-pharmacological approaches including psychological therapies, acupuncture, exercise programmes and social prescribing. For example, I would love to be able to refer patients with chronic pain to a trained professional who has the time I do not have to coach, guide, counsel and support them. Hopefully the guideline will drive that service change and make these therapies and therapists more accessible, but in the meantime it highlights the need for a more honest dialogue with patients about expectations from treatment so that patients can make truly informed decisions.
The draft guideline is out for consultation and the final version will publish next year. It will be interesting to see if the final conclusions are ‘watered down’…I, for one, hope not. Let's be bold, throw away the prescription pad and make a new start for our patients with chronic pain. They deserve better.
We shall discuss the recommendations in full on our Autumn courses, with other evidence-based interventions that may help our patients with chronic pain. We hope to see you then!
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