Sachin Tammewar discusses the recommendations of NICE Guideline 193, which puts patients at the centre of care for chronic pain

Tammewar, Sachin

Sachin Tammewar

Read this article to learn more about:

  • the different types of chronic pain, and the impact on those living with pain
  • first-line treatment with non-pharmacological measures, such as exercise and cognitive behavioural therapy
  • the risks and benefits of pharmacological treatment of chronic pain.

Read this article online at: GinP.co.uk/456098.article

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In April 2021, NICE published NICE Guideline (NG) 193, Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain.1 Despite its title, NG193 does not cover all types of chronic pain—where guidance already exists for specific chronic secondary pain conditions (for example, headaches, low back pain and sciatica, rheumatoid arthritis, osteoarthritis, spondyloarthritis, endometriosis, neuropathic pain, and irritable bowel syndrome), those guidelines should be followed, and NG193 should be used alongside them.1 This article discusses the recommendations of NG193 on the assessment of all types of chronic pain and the management of chronic primary pain.

What is chronic pain?

Chronic pain is defined as pain that persists for a period of 3 months or more.1,2 It is a common condition—in 2016, chronic pain was estimated to affect between one-third and half of the population of the UK2 —that places a considerable burden on both individuals and society.1 The Global Burden of Disease Study 2017 highlighted pain as one of the most prominent causes of disability worldwide—low back pain, and headache were identified as leading causes of disability, with other chronic pain conditions accounting for many of the top 10 causes of disability.3 Chronic pain has a significant impact on people’s lives, and is linked with negative consequences such as depressive disorder, substance abuse, loss of earnings or employment, reduced or poor quality of life, and disruption of daily activities, including sleep.1

Published in December 2020, the report Chronic pain in adults 2017—health survey for England4 explored the responses to questions on chronic pain included in the Health survey for England 2017.5 The main findings of the report were that, in 2017, 34% of respondents reported some degree of chronic pain4 —a figure that was unchanged from 2011, when questions on chronic pain were last included in the survey.5 The report identified that the prevalence of chronic pain increased with age, ranging from 18% among those aged 16–34 years to 53% in those aged 75 years and over.4 Chronic pain was also more prevalent among women (38%) than men (30%).4 Furthermore, people living in deprived areas were more likely to report chronic pain (41%) than those resident in the least deprived areas (30%).4

Types of chronic pain

For the first time, the World Health Organization has provided specific pain diagnoses in International classification of diseases 11th revision (ICD-11). Whereas the previous version included only chronic intractable pain and other chronic pain,6 ICD-11 features separate entries for chronic primary pain, chronic secondary pain, and a number of other chronic pain conditions.7

Chronic primary pain

Chronic primary pain is defined as pain that lasts for longer than 3 months that cannot be explained by another condition.1,7 Chronic primary pain is associated with significant emotional distress and functional disability, and is best viewed as a health condition in its own right.1,7 Examples of chronic primary pain include fibromyalgia, complex regional pain syndrome, chronic primary headache and orofacial pain, chronic primary visceral pain, and chronic primary musculoskeletal pain.1

Chronic secondary pain

Chronic secondary pain is defined as pain secondary to another condition;1,7 however, a diagnosis of chronic secondary pain indicates that the chronic pain has become a problem independent of the underlying condition. Examples of chronic secondary pain include chronic pain related to cancer, surgery, injury, visceral disease, musculoskeletal disease, or nerve damage and headaches.7

Types of chronic pain in NG193

The NICE guideline on chronic pain recognises the new classifications of chronic primary pain and chronic secondary pain, enabling healthcare professionals to look at the different approaches that are available at a local level to manage pain more effectively.1 In addition, the new guidance helps clinicians to recognise that chronic primary pain can coexist with chronic secondary pain.1

Assessing chronic pain

NICE recommends that clinicians should conduct a holistic, person-centred assessment of individuals presenting with chronic pain that examines the causes and impacts of the pain (see Box 1 and Figure 1).

Box 1: Assessing all types of chronic pain1

Person-centred assessment

  • Offer a person-centred assessment to those presenting with chronic pain (chronic primary pain, chronic secondary pain, or both) to identify factors contributing to the pain and how the pain affects the person’s life
  • When assessing and managing any type of chronic pain (chronic primary pain, chronic secondary pain, or both), follow the recommendations in the NICE guideline on patient experience in adult NHS services,[A] particularly relating to:
    • knowing the patient as an individual
    • enabling patients to actively participate in their care, including:
      • communication
      • information
      • shared decision making
  • Foster a collaborative and supportive relationship with the person with chronic pain.

Thinking about possible causes for pain

  • Think about a diagnosis of chronic primary pain if there is no clear underlying (secondary) cause, or the pain or its impact is out of proportion to any observable injury or disease, particularly when the pain is causing significant distress and disability
  • Make decisions about the search for any injury or disease that may be causing the pain, and about whether the pain or its impact are out of proportion to any identified injury or disease, using clinical judgement in discussion with the person with chronic pain
  • Recognise that an initial diagnosis of chronic pain may change with time. Re-evaluate the diagnosis if the presentation changes
  • Recognise that chronic primary pain can coexist with chronic secondary pain. 

Talking about pain—how this affects life and how life affects pain

  • Ask the person to describe how chronic pain affects their life, and that of their family, carers, and significant others, and how aspects of their life may affect their chronic pain. This might include:
    • lifestyle and day-to-day activities, including work and sleep disturbance
    • physical and psychological wellbeing
    • stressful life events, including previous or current physical or emotional trauma
    • current or past history of substance misuse
    • social interaction and relationships
    • difficulties with employment, housing, income, and other social concerns
  • Be sensitive to the person’s socioeconomic, cultural, and ethnic background, and faith group, and think about how these might influence their symptoms, understanding, and choice of management
  • Explore a person’s strengths as well as the impact of pain on their life. This might include talking about:
    • their views on living well
    • the skills they have for managing their pain
    • what helps when their pain is difficult to control
  • Ask the person about their understanding of their condition, and that of their family, carers, and significant others—this might include:
    • their understanding of the causes of their pain
    • their expectations of what might happen in the future in relation to their pain
    • their understanding of the outcome of possible treatments
  • When assessing chronic pain in people aged 16 to 25 years, take into account:
    • any age-related differences in presentation of symptoms
    • the impact of the pain on family interactions and dynamics
    • the impact of the pain on education and social and emotional development
  • Recognise that living with pain can be distressing, and acknowledge this with the person with chronic pain.

[A] NICE. Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. Clinical Guideline 138. NICE, 2012 (last updated 2021). Available at: www.nice.org.uk/cg138

© NICE 2021. Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. www.nice.org.uk/ng193

All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

NG193 visual summary

Figure 1: Primary and secondary chronic pain—visual summary of the recommendations of NICE Guideline 1931

© NICE 2021. Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE Guideline 193. NICE, 2021. Tools and resources. Available at: www.nice.org.uk/ng193/resources

All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

A patient-centred approach

In the assessment of chronic pain, NICE recommends that the person is given relevant advice and information ‘to the person’s individual preferences, at all stages of care’ to help them make decisions about managing their condition (see Box 2).

Box 2: Assessing all types of chronic pain—advice, care, and support1

Providing advice and information

  • Provide advice and information relevant to the person’s individual preferences at all stages of care, to help them make decisions about managing their condition, including self-management
  • Discuss with the person with chronic pain and their family or carers (as appropriate):
    • the likelihood that symptoms will fluctuate over time and that they may have flare-ups
    • the possibility that a reason for the pain (or flare-up) may not be identified
    • the possibility that the pain may not improve or may get worse and may need ongoing management
    • there can be improvements in quality of life even if the pain remains unchanged.
  • When communicating normal or negative test results, be sensitive to the risk of invalidating the person’s experience of chronic pain.

Developing a care and support plan

  • Discuss a care and support plan with the person with chronic pain. Explore in the discussions:
    • their priorities, abilities, and goals
    • what they are already doing that is helpful
    • their preferred approach to treatment, and balance of treatments for multiple conditions
    • any support needed for young adults (aged 16–25) to continue with their education or training, if this is appropriate
  • Explain the evidence for possible benefits, risks, and uncertainties of all management options when first developing the care and support plan and at all stages of care
  • Use these discussions to inform and agree the care and support plan with the person with chronic pain and their family or carers (as appropriate)
  • Offer management options:
    • in line with section 1.2 of [NG193] if the assessment suggests the person has chronic primary pain
    • in line with the NICE guideline for the underlying chronic pain condition (see the NICE pathway on chronic pain)[A] if the underlying condition adequately accounts for the pain and its impact
  • When chronic primary pain and chronic secondary pain coexist, use clinical judgement to inform shared decision making about management options in section 1.2 of [NG193] and in the NICE guideline for the chronic pain condition.

[A] NICE. Chronic pain (primary and secondary) overview. NICE Pathway. pathways.nice.org.uk/pathways/chronic-pain-primary-and-secondary (accessed 23 June 2021).

© NICE 2021. Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary painwww.nice.org.uk/ng193

All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

Management options for chronic primary pain

The fundamental aim of the guideline is to enable patients with primary chronic pain to achieve as normal a life as possible by reducing physical disability and emotional trauma. NG193 provides recommendations on the management of chronic primary pain, for which it advocates a nonpharmacological approach (see Figure 1).1 Patients with chronic primary pain should not be treated with pain-relief medication; instead, they should have access to a range of nonpharmacological options to help manage their condition.1

Nonpharmacological management

Based on the symptoms presented by the patient and the needs uncovered by their assessment, nonpharmacological treatment should be offered, such as an exercise programme.

Patients presenting with chronic primary pain in primary care should be counselled on the general health benefits of remaining physically active where appropriate; for specific ‘exercise prescriptions’, the mnemonic FITT can be used to build an exercise plan as follows:8

  • F—frequency (at least 2–3 days a week)
  • I—intensity (low, moderate, or vigorous)
  • T—time (at least 20–60 minutes)
  • T—type (mode of exercise).

An example of such a scheme is one run by the Well Doncaster programme, established by Doncaster CCG.9 It is a community-based peer support group that provides education and support to people with fibromyalgia and chronic pain. The initiative offers advice on chronic pain management, diet, exercise, and psychological support, and represents an important network where people with chronic pain can talk to others living with the condition.

NICE NG193 also recommends psychological therapies such as acceptance and commitment therapy (ACT), cognitive behavioural therapy (CBT), or acupuncture for people aged 16 years or over (see the guideline for further details).1 However, NICE states that there is no evidence that electrical physical modalities, such as transcutaneous electrical nerve stimulation or ultrasound therapy, are of any benefit in the management of chronic primary pain.1

Pharmacological management

If pharmacological treatment is required, an antidepressant (amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine, or sertraline) should be considered as the first-line option for the management of chronic primary pain in people aged 18 years or over, even in the absence of depression, following a full discussion of the potential benefits and harms.1 Prior to starting antidepressants, it is important to discuss with the patient commonly and very commonly reported adverse effects observed via spontaneous reporting and in placebo-controlled clinical trials, particularly those related to musculoskeletal pain, to avoid the use of an antidepressant becoming the problem it was initiated to treat.10–17

NICE recommends that people with chronic primary pain should not be started on medicines commonly used to treat pain, such as paracetamol, nonsteroidal anti-inflammatory drugs, benzodiazepines, antiepileptic drugs including gabapentinoids, antipsychotic drugs, or opioids.1 According to NICE, there is little or no evidence that these drugs make a difference to the quality of life of people with chronic primary pain, but they can cause harm and lead to addiction.1 For patients with chronic primary pain already taking one of these pharmacological treatments, a shared-care agreement should be drawn up with the patient explaining the benefits and risks of continuing to take these medications; in addition, a review should be scheduled.1

What should a review meeting consist of?

As part of shared decision making, patients should be regularly reviewed to assess the benefits and harms of their treatment.1

In my practice, initial review meetings take place monthly, then at 3- and 6-monthly intervals thereafter. Consideration should be given to whether the patient would benefit from an extended appointment.

As part of the review meeting for patients with chronic primary pain:

  • offer patients information on self-management, such as the Faculty of Pain Medicine’s About pain (bit.ly/2TUAKAI)
  • set manageable goals and identify the steps necessary to work towards them
  • ensure that nonpharmacological strategies have been adequately implemented when considering pharmacological treatment
  • discuss medication with the patient—does it reduce their pain and improve their quality of life? If the answer is no, then agree a plan to reduce or stop taking medications.

Barriers to implementation of the guidance

Access to exercise programmes and psychological therapies such as ACT and CBT may differ across the country; some trusts may not provide these services, and in areas that do, waiting times can be lengthy. Currently, the NICE guidance does not specify how chronic primary pain should be managed while a patient is waiting to access therapy. In addition, standard 5–10-minute GP appointment slots are insufficient to have open and collaborative dialogue—sometimes, back-to-back, extended appointments are necessary. These and other obstacles should be considered at the practice level before implementing this guideline.

Summary

The NICE guideline on chronic pain provides advice to clinicians on the effective management of chronic primary pain. It encourages open dialogue with the patient, and advocates shared decision making with a patient-centred approach. The guidance discourages the initiation of pharmacological treatments (other than antidepressants) for chronic primary pain because, based on the evidence, they have little or no benefits but may carry significant risks, such as addiction. Instead, NG193 recommends that clinicians consider nonpharmacological options such as exercise programmes and psychological therapies to manage chronic primary pain; however, it is important to remember that access to these nonpharmacological therapies varies across the country—an issue that needs to be addressed at the earliest opportunity.

Key points

  • Chronic pain, which is defined as pain lasting for more than 3 months, can either be:
    • primary (no clear underlying condition and disproportionate to any observable injury or disease)
    • secondary (caused by an underlying condition)
  • NG193 emphasises shared decision making, putting patients at the centre of their care, and fostering a collaborative, supportive relationship between patients and clinicians
  • Options for the management of chronic primary pain include exercise programmes, CBT, and acupuncture
  • When pharmacological treatment is considered necessary, an antidepressant should be used as the first-line agent
  • Medicines commonly used to manage chronic primary pain—including opioids, paracetamol, nonsteroidal anti-inflammatory drugs, benzodiazepines, antipsychotics, and gabapentinoids—should not be initiated; there is a lack of evidence that these medicines improve quality of life and they may cause more harms than benefits
  • If patients are currently receiving a pharmacological treatment regimen that is ineffective, review with a view to gradually reducing or stopping the medication.

CBT=cognitive behavioural therapy

Useful resources

Websites

Videos

Sachin Tammewar

Practice-based pharmacist and independent prescriber, Doncaster

At the time of publication (August 2021), some of the drugs discussed in this article did not have UK marketing authorisation for the indications discussed. Prescribers should refer to the individual summaries of product characteristics for further information and recommendations regarding the use of pharmacological therapies. For off-licence use of medicines, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices (bit.ly/3z5InVn) for further information.

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved in implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.

  • Conduct a self-assessment of pathways for chronic pain in your area and identify which services recommended by NICE are deficient or have long waiting times
  • Give clear information on formulary sites for the indications for drugs used to treat pain, especially those with addictive potential
  • Ensure that there is prompt access to psychological services providing CBT and other therapies proven to be of benefit in managing chronic pain
  • Identify the need to support primary care to manage patients with chronic pain, and de-escalate pharmacotherapies such as opiates, which are harmful
  • Consider offering advice and guidance services, as well as formal appointments, from specialist pain clinics to give referring clinicians rapid access to advice that may help to prevent pain from becoming chronic in the first place.

STP=sustainability and transformation partnership; ICS=integrated care system; CBT=cognitive behavioural therapy

Implementation actions for clinical pharmacists in general practice

written by Kajal Mistry, Associate Director, Soar Beyond Ltd

The following implementation actions are designed to support clinical pharmacists in general practice with implementing the guidance at a practice level. 

Following the recent reinstatement of the NHS England DES,[A] one area of focus for clinical pharmacists in general practice when undertaking SMRs will be patients receiving potentially addictive pain-management medication. Consistently, the recent NICE guideline on chronic pain recommends that prescribing is reviewed in patients with chronic primary pain to ensure that they are being managed in line with current guidance and best practice.[B]

Clinical pharmacists are optimally placed to conduct these reviews because of their extensive knowledge of medications; in addition, they have the ability to look at the bigger picture, taking into account patients’ other comorbidities and medications, as well as to explore nonpharmacological interventions.

When conducting pain-medication reviews, pharmacists should adopt a holistic approach and consider the following, as per NICE Guideline 193:[B]

  • incorporating shared decision making to achieve the maximum benefit of, and reduction in harm related to, pain medication
  • placing patients at the centre of their care
  • promoting a collaborative and supportive relationship with the patient
  • providing individualised goals, with a focus on patient priorities
  • encouraging self-management strategies, with the aim of empowering the patient.

The pharmacist’s role in medicines optimisation for chronic pain can include:

  • ensuring that patients are on a safe and effective dose to manage their pain[B]
  • responsible and appropriate prescribing, ensuring that consideration has been given to the risks and benefits of treatment options[B]
  • assessing adherence to the current regimen prior to uptitrating[C]
  • using evidence-based medication[C]
  • reviewing any OTC medication
  • creating a pain register to ensure that patients’ medications are regularly reviewed.

Clinical pharmacists working in general practice should use both the NICE Guideline on chronic pain[B] and their expertise by placing the patient at the centre of these reviews—this will ensure an open and honest discussion, which will ultimately lead to the best possible outcome for the patient.

[A] NHS England. Network contract directed enhanced service—structured medication reviews and medicines optimisation: guidance. London: NHS England, 2021. Available at: www.england.nhs.uk/wp-content/uploads/2021/03/B0431-network-contract-des-smr-and-mo-guidance-21-22.pdf

[B] NICE. Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE Guideline 193. NICE, 2021. Available at: www.nice.org.uk/ng193

[C] Royal Pharmaceutical Society. Medicines optimisation: helping patients to make the most of medicines. London: RPS, 2013. Available at: www.rpharms.com/Portals/0/RPS document library/Open access/Policy/helping-patients-make-the-most-of-their-medicines.pdf

DES=Directed Enhanced Service; SMR=structured medication reviews; OTC=over-the-counter

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References

  1. NICE. Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE Guideline 193. NICE, 2021. Available at: www.nice.org.uk/ng193
  2. Fayaz A, Croft P, Langford R et al. Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. BMJ Open 2016; 6 (6): e010364.
  3. GBD 2017 Disease and injury incidence and prevalence collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392 (10159): 1789–1858.
  4. Public Health England. Chronic pain in adults 2017—health survey for England. London: PHE, 2020. Available at: www.gov.uk/government/publications/chronic-pain-in-adults-2017
  5. NHS Digital. Health survey for England 2017 [NS]. digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/2017 (accessed 6 July 2021).
  6. World Health Organization. International classification of diseases and related health problems 10th revision. icd.who.int/browse10/2010/en (accessed 6 July 2021).
  7. World Health Organization. International classification of diseases 11th revision (ICD-11). icd.who.int/browse11/l-m/en (accessed 6 July 2021).
  8. Kester S. About the FITT principle. Healthline Media, 2020. www.healthline.com/health/fitt-principle (accessed 6 July 2021).
  9. Well Doncaster website. All the news and updates from Well Doncaster. welldoncaster.wordpress.com (accessed 6 July 2021).
  10. British National Formulary website. Amitriptyline hydrochloridebnf.nice.org.uk/drug/amitriptyline-hydrochloride.html (accessed 2 August 2021).
  11. British National Formulary website. Citaloprambnf.nice.org.uk/drug/citalopram.html (accessed 2 August 2021).
  12. British National Formulary website. Duloxetinebnf.nice.org.uk/drug/duloxetine.html (accessed 2 August 2021).
  13. British National Formulary website. Fluoxetine. bnf.nice.org.uk/drug/fluoxetine.html (accessed 2 August 2021).
  14. British National Formulary website. Paroxetinebnf.nice.org.uk/drug/paroxetine.html (accessed 2 August 2021).
  15. British National Formulary website. Sertralinebnf.nice.org.uk/drug/sertraline.html (accessed 2 August 2021).
  16. Brown M. Chronic pain (primary and secondary) in over 16s: summary of NICE guidance. Rapid response. BMJ  2021; 373: n895.
  17. Van Leeuwen E, van Driel M, Horowitz M et al. Approaches for discontinuation versus continuation of long‐term antidepressant use for depressive and anxiety disorders in adults. Cochrane Database Syst Rev 2021; (4):  CD013495.

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