What's New in NICE Chronic Pain Management Guidance?

Dr Rob Hicks

Disclosures

May 24, 2021

Hello, and welcome to this Medscape UK video. I'm Dr Rob Hicks. Today we're going to be talking about the new chronic pain guideline from the National Institute for Health and Care Excellence (NICE) and I'm delighted to have here with me, Dr Benjamin Ellis, who is a consultant rheumatologist at Imperial College Healthcare NHS Trust, and a member of the NICE chronic pain guideline committee. Welcome, Benjamin. And thank you for joining me today.

I'd like to begin by asking you, why do we need this guideline?

Dr Ellis

This guideline is really important because we have a large number of people with chronic pain and a large number of those have chronic primary pain. Guidelines we've had in the past have focused on the conditions that cause pain - conditions like osteoarthritis, conditions like back pain. But what we haven't had is a guideline, particularly for this group of people with chronic primary pain – and we'll say a little bit more about what that is - but that includes conditions like fibromyalgia.

So in the absence of a guideline we believe there's been a lot of variation in practice, people doing different things, and it's possible that some treatments that could be quite helpful for people, people haven't been able to access. And the hope is that a guideline addressing this will improve the access to these approaches for people who are living with chronic primary pain, while at the same time trying to reduce the number of people that are offered therapies which are not helpful for chronic primary pain in particular.

Dr Hicks

Could you define for us chronic primary pain, and chronic secondary pain? You know, what those two conditions mean?

Dr Ellis

These are fairly new terms to most people, and I think one of the challenges with the guideline is that people will be hearing these terms for the first time. And so I think it's really helpful to review what we mean by these terms.

Perhaps it's easier to start with chronic secondary pain. So chronic secondary pain is pain, which is chronic, it lasts for 3 months or more is one well accepted definition, and this is pain which is caused by underlying damage, or inflammation, and which could be in various tissues. So in osteoarthritis you have damage to a joint, in rheumatoid arthritis you have inflammation, you might have neuropathic pain, nerve pain, where there is damage or inflammation in the nerve causing the pain, or perhaps endometriosis causing pelvic pain.

So these are types of chronic secondary pain, where the aim and treatment often is to try to reverse the underlying problem. If we can treat the inflammation and stop the damage, the assumption is that the pain will improve or at the very least, stop getting any worse.

Chronic primary pain is pain where the pain is not due to underlying damage or inflammation in the tissue, particularly where the pain is being felt.

There are a number of different conditions that come under chronic primary pain that are classic, and one that I would see a lot in clinic would be a condition like fibromyalgia, where people feel pain all over, although there is no damage that can be found in the joints or muscles or bones. Or perhaps there is some damage, but the pain that people are experiencing is way out of proportion.

There are a number of different forms of chronic primary pain, and these have been brought together as a group of conditions for the first time in the most recent World Health Organisation classification, ICD11 Classification of Diseases.

Some people have felt that this group of conditions isn't necessarily a group of natural bedfellows, that it may be that the aetiologies of these conditions are different, or that the approaches to these conditions should be different. But when the scope of the guideline was written, the respondents, and therefore NICE, suggested that this is what we look at.

To make sure we weren't missing any differences between conditions and not to make the automatic assumption that the conditions had things necessarily in common, we did look separately for each of the conditions under chronic primary pain to make sure we weren't missing any evidence. And if there was any differences in approaches that came out from the evidence, we committed to talking about them, and you can see the full discussion in the guideline.

Dr Hicks

What would you say is the most challenging aspect of managing somebody with chronic pain?

Dr Ellis

Chronic pain is always challenging for the people living with it, and for those of us who are in our professional roles trying to support, help, and treat people with chronic pain. I think one of the challenges, particularly thinking about chronic primary pain and chronic secondary pain, is trying to get to the bottom of what's causing the pain. And many people with chronic pain will tell you that they've been on a journey where perhaps they feel they haven't been listened to early on, and then they've had large numbers of tests, they've seen very many specialists, and it's unclear to the person living with chronic pain what their pain is. And people get into quite a complex cycle sometimes, of investigations which are unhelpful, treatments which don't work and cause side effects, which compounds the distress that a lot of people with chronic pain in any case have in their lives, both because of the condition, and with chronic primary pain in particular, because we know that life stress and distress both leads to, and exacerbates, the pain people have.

So I think the interpersonal side is very challenging, and the diagnostic side is very challenging. And one of the things that is in the guideline, and a lot of this came in as we reviewed the comments that we had after the round of stakeholder input, is the opening sections of the guideline where we try to outline a framework for the approach to the person who presents with chronic pain.

And this has to be a very person-centred approach. And it has to be a substantial exploration into all the different factors, the psychological factors, the social factors, as well as the biological factors that are contributing to people's chronic pain, recognising that chronic pain is often complex, and is often not due to just one of these things, but often a combination.

And I think recognising as well, not to be too anxious about making the diagnosis, or a provisional diagnosis, of chronic primary pain in somebody where the pattern seems to fit. So where an initial history, examination, and some initial testing, suggests that there is not an underlying secondary cause, but the pain itself is the primary condition. That's chronic primary pain. Not being afraid to make that as an initial diagnosis and offer explanation and support, even while at the same time perhaps continuing to look for other causes that might be contributing to it, forms of chronic secondary pain, because of course, the two can coexist.

And then it's a complex process of working together with the person with chronic pain to understand what they want to do, what matters to them, and then what support and approaches, and sometimes medical treatments, might help them.

So it's the sort of complexity that I think a lot of people in any case are delivering all the time in primary care. But I think making sure that we bring this to people who are living with chronic pain - both chronic primary pain and chronic secondary pain - understanding the interplay between the two, and using the consultation skills that most of us already have, and have well, bringing that to bear in chronic pain to support people to live well.

Dr Hicks

The guideline recommends actually not initiating certain treatments, for example, paracetamol, and non-steroidal anti-inflammatory drugs. Why is this?

Dr Ellis

The issue of medication, I think, has been one of the more contested parts of the guideline. And, in some ways it's understandable why this might be. It’s the first time there has been a guideline focusing on chronic primary pain, and so there is a lot of variation in practice. And when a guideline comes into a space for a first time, it's understandable that both people living with chronic pain and practitioners might be anxious about this constraining people's freedom to prescribe and to use medications.

Before I say something about paracetamol and non-steroidal anti-inflammatories, I think it's therefore worth saying the guideline is clear that if people are taking medications, and those medications are helpful for that individual, it's worth having a conversation with people about whether they want to continue those medications, and outlining risks and benefits. But we shouldn't be taking people off treatments that they say are helpful for them.

I think that's a really important message. There is a lot of worry out there. And it's really important that as clinicians, we have a responsibility to emphasise that to people with chronic pain, because nobody deserves to be in fear of having something that they find helpful taken away.

The guideline makes recommendations against a number of medicines that are used in chronic pain quite widely at the moment in some places, particularly medicines, the gabapentinoids, that's medicines like pregabalin and gabapentin, and also medicines, the opioids, as well as you say paracetamol and non-steroidal anti-inflammatories. And the reason for this is that when we looked for evidence of the quality of evidence that NICE will accept for a NICE guideline, we weren't able to find high quality evidence that these medicines were beneficial. And we were able to find plenty of evidence that these medicines can be harmful.

So I think that is the guiding principle, that medicines - in particular the gabapentinoids and opioids - carry significant levels of harm, but there wasn't the evidence there showing the benefit.

A question’s come up as well. Well what should we be doing if people flare then? Can we not even use these during a flare? And the guideline again, in the opening sections where we talk about the overall approach, talks a bit about flares. And the approach to a flare, as with other conditions, has to be, first of all, to explore what were the precipitating factors. And with chronic primary pain in particular, we do have to remember to look at the psychological factors and the social factors that might have precipitated a flare. To recognise that chronic pain conditions do wax and wane and that flaring can happen in these conditions, and there isn't always a reason. And then to recognise that somebody can have a pain flare because they've developed a new condition. Somebody could have developed rheumatoid arthritis, or could have developed endometriosis, or another condition at the same time.

So we must always take people's flares seriously - take a careful history, examine, and investigate if need be.

The reason for not recommending medicines like these, in the context of a flare, is simply because we don't have the evidence that they work. And we shouldn't be using medicines in the absence of evidence where they work.

If people are suggesting - well couldn't we just try these medicines? We know they may work, or we think they may work for a small number of people, we all have a small number of patients who say they benefit, would it not make sense to have a trial of these medicines? But the risk with that is we know that the harms outweigh the benefits, that these medicines are associated with dependence, and sometimes addiction, and therefore that we're putting patients at risk, which can outweigh the benefits, if we say we're going to prescribe these to people just to see if they give any benefit.

Dr Hicks

Were you surprised that some treatments, for example acupuncture, are being recommended in the guideline?

Dr Ellis

Having seen the evidence, I'm no longer surprised. But I didn't go into the guideline process expecting that we would end up recommending acupuncture – and I'm not sure many of those of us who are on the committee did. However, when we saw the evidence for acupuncture, bringing together the studies - mainly in musculoskeletal conditions, but also, I think there were a couple of studies looking at pelvic pain as well – and when we saw the evidence put together, it was as good as the evidence in other areas that we also recommended.

So I think it's a surprise to us - a lot of us would have had the experience of seeing acupuncture services decommissioned in recent years. And acupuncture is not recommended in other guidelines such as osteoarthritis or back pain, but for chronic primary pain, where that is the key presentation, there does seem to be evidence that it can be helpful, certainly for some people and certainly to cross the threshold where we felt comfortable making the recommendation.

Many questions remain. We felt on the basis of the health economics able to recommend a single course of acupuncture in a certain setting, which was driven very much by the need for cost effectiveness, which is an important aspect for NICE as the guidance for the custodians of public spending. And things remain unclear. Can people have a second course? When might that be appropriate? And these are things where we simply weren't able to make a recommendation. And as always, guidelines are guidelines, they’re not tramlines. And even in the presence of a guideline such as this, we are all left needing to make some clinical decisions individually, with our patients and with colleagues who are helping to provide the service.

Dr Hicks

Well, that's all we have time for today. We hope you found our discussion interesting. If you've any comments, we'd love to hear from you.

So thank you once again Benjamin for joining me today. And thank you all for watching.

Dr Benjamin Ellis, Consultant Rheumatologist, Imperial College Healthcare NHS Trust, London. Member of National Institute for Health and Care Excellence (NICE) chronic pain guidance committee. Dr Ellis has no relevant disclosures.

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