Chronic pain (primary and secondary) in over 16s: summary of NICE guidance
BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n895 (Published 21 April 2021) Cite this as: BMJ 2021;373:n895
- Serena Carville, associate director1,
- Margaret Constanti, senior health economist1,
- Nick Kosky, consultant psychiatrist2,
- Cathy Stannard, consultant in complex pain and clinical lead of pain programme3,
- Colin Wilkinson, lay member of Guideline Committee4
- on behalf of the Guideline Committee
- 1National Guideline Centre, Royal College of Physicians, London NW1 4LE, UK
- 2Dorset HealthCare NHS Foundation Trust, Poole, UK
- 3NHS Gloucestershire CCG, Gloucester, UK
- 4Stockton-on-Tees, UK
- Correspondence to: S Carville serena.carville{at}rcp.ac.uk
What you need to know
A collaborative and supportive relationship between healthcare professional and person with chronic pain and a comprehensive person-centred assessment are central to good management
With the exception of antidepressants, initiation of pharmacological management is not recommended.
Offer supervised group exercise to people with chronic primary pain
Chronic pain—defined as pain that lasts for more than three months—is common, debilitating, and often difficult to treat.1 Chronic pain is classified in ICD-11 as being either primary or secondary. In chronic primary pain there is no clear underlying condition that adequately accounts for the pain or its impact; chronic secondary pain is pain linked to an underlying condition.2 Clinical judgment is required to determine whether the pain is primary, secondary, or a combination of the two (box 1).
Identifying chronic primary pain
Chronic primary pain has no clear underlying condition, or the pain or its impact seems to be out of proportion to any observable injury or disease. All forms of pain can cause distress and disability, but these features are particularly prominent in presentations of chronic primary pain.
The guideline is consistent with the ICD-11 definition of chronic primary pain: “Chronic primary pain is chronic pain in one or more anatomical regions that is characterised by significant emotional distress (anxiety, anger/frustration or depressed mood) or functional disability (interference in daily life activities and reduced participation in social roles). Chronic primary pain is multifactorial: biological, psychological and social factors contribute to the pain syndrome. The diagnosis is appropriate independently of identified biological or psychological contributors unless another diagnosis would better account for the presenting symptoms.”4
RETURN TO TEXTThis article summarises recommendations from the National Institute for Health and Care Excellence (NICE) guideline for chronic pain (primary and secondary) in people over 16 years old for use in all NHS settings where pain is managed.3 The guideline, published in April 2021, covers assessment for people living with primary or secondary chronic pain and management of chronic primary pain.
Recommendations
NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Committee’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.
Assessing all types of chronic pain (chronic primary pain, chronic secondary pain, or both)
Qualitative evidence demonstrates shortcomings in people’s experience of healthcare consultations. Evidence reviewed in the guideline highlights that the principles of best practice in supporting people with long term conditions are central in supporting people with pain. The Guideline Committee therefore agreed that this should be addressed within the guideline and several recommendations were made for clinicians assessing people with chronic pain. The evidence demonstrated the pivotal importance of an empathic and supportive therapeutic relationship between people with pain and healthcare professionals that underpins decision making and care and support planning. Other recommendations address developing an understanding of the experience of the person with pain and providing advice and information.
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. [Based on data from qualitative studies with moderate confidence in the evidence]
Foster a collaborative and supportive relationship with the person with chronic pain. [Based on data from qualitative studies with high confidence in the evidence]
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. [Based on the experience and opinion of the Guideline Committee (GC)]
Recognise that chronic primary pain can co-exist with chronic secondary pain. [Based on the experience and opinion of the GC]
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.
[Based on the experience and opinion of the GC]
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.
[Based on the experience and opinion of the GC]
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.
[Based on data from qualitative studies with low confidence in the evidence and the experience and opinion of the GC]
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 (16-25 years old) to continue with their education or training, if this is appropriate.
[Based on the experience and opinion of the GC]
Explain the evidence for possible benefits, risks, and uncertainties of all management options when first developing the care plan and at all stages of care. [Based on data from qualitative studies with high confidence in the evidence]
Managing chronic primary pain (CPP)
The guideline makes recommendations for managing chronic primary pain. When chronic primary and secondary pain coexist, management should be guided by both the recommendations in this section and the NICE guideline for the secondary pain condition. The guideline committee agreed that shared decisions to inform a care and support plan should be based on discussion of risks and benefits of potential options known to be effective for chronic primary pain.
There was consistent evidence of benefit for non-pharmacological approaches, which the committee agreed could be considered as treatment options according to individual needs and preferences. Evidence was particularly strong for group exercise, which the committee agreed could be offered to all people with chronic primary pain. In contrast, the committee recommended not initiating medicines for chronic pain (with the exception of antidepressants, which can be considered after a full discussion of the benefits and harms). The evidence review found that most medicines do not demonstrate a benefit compared with placebo in the management of chronic primary pain; some demonstrate a risk of harm. such as the risk of misuse and dependence with opioids and gabapentinoids.
Offer a supervised group exercise programme to people aged 16 years and over to manage chronic primary pain. Take people’s specific needs, preferences, and abilities into account. [Based on high to very low quality randomised trial data and original economic modelling]
Consider acceptance and commitment therapy or cognitive behavioural therapy for pain for people aged 16 years and over with chronic primary pain delivered by healthcare professionals with appropriate training. [Based on moderate to low quality randomised trial data]
Consider a single course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system, for people aged 16 years and over to manage chronic primary pain, but only if the course:
Is delivered in a community setting and
Is delivered by a healthcare professional at band 7 equivalent or lower with appropriate training and
Is made up of no more than 5 hours of healthcare professional time (the number and length of sessions can be adapted within these boundaries) or
Is delivered by another healthcare professional with appropriate training and/or in another setting for equivalent or lower cost.
[Based on moderate to very low quality randomised trial data with a large number of participants and original economic modelling]
Do not offer any of the following to people aged 16 years and over to manage chronic primary pain because there is no evidence of benefit:
TENS (transcutaneous electrical nerve stimulation)
Ultrasound therapy
Interferential therapy.
[Based on high to very low quality randomised trial data with a small number of participants and the experience and opinion of the GC]
Consider an antidepressant—either amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine, or sertraline—for people aged 18 years and over to manage chronic primary pain, after a full discussion of the benefits and harms. [Based on high to very low quality randomised trial data]
If an antidepressant is offered to manage chronic primary pain, explain that this is because these medicines may help with quality of life, pain, sleep, and psychological distress, even in the absence of a diagnosis of depression. [Based on high to very low quality randomised trial data]
Do not initiate any of the following medicines to manage chronic primary pain in people aged 16 years and over:
Antiepileptic drugs, including gabapentinoids, unless gabapentinoids are offered as part of a clinical trial for complex regional pain syndrome (see research recommendations)
Antipsychotic drugs
Benzodiazepines
Corticosteroid trigger point injections
Ketamine
Local anaesthetics (topical or intravenous), unless as part of a clinical trial for complex regional pain syndrome (see research recommendations)
Local anaesthetic-corticosteroid combination trigger point injections
Non-steroidal anti-inflammatory drugs
Opioids
Paracetamol.
[Based on high to very low quality randomised trial data and the experience and opinion of the GC]
If a person with chronic primary pain is already taking any of the medicines in the recommendation above, review the prescribing as part of shared decision making:
Explain the lack of evidence for these medicines for chronic primary pain and
Agree a shared plan for continuing safely if they report benefit at a safe dose and few harms or
Explain the risks of continuing if they report little benefit or significant harm and encourage and support them to reduce and stop the medicine if possible.
[Based on the experience and opinion of the GC]
When making shared decisions about whether to stop antidepressants, opioids, gabapentinoids, or benzodiazepines, discuss with the person any problems associated with withdrawal. [Based on the experience and opinion of the guideline committee]
Implementation
The guideline highlights the lack of evidence of effectiveness for most medicines for chronic primary pain, and the risk of harms. Healthcare professionals should be supported in managing challenging conversations with people with chronic primary pain when explaining this evidence. This can be assisted through having a better understanding of people’s previous experiences of unsatisfactory interactions and a clearer understanding of the lack of efficacy of some commonly used treatments. For people already receiving treatments, healthcare professionals also need to be appropriately skilled to facilitate deprescribing of medicines where appropriate.
The guideline recommends considering a course of acupuncture. Acupuncture is not widely available within the NHS for people with chronic primary pain. In addition, access to other treatments such as group exercise, acceptance and commitment therapy, and cognitive behavioural therapy varies across the country. Support in signposting to and commissioning these services will be required to effectively implement the guideline. The recommendation for acupuncture specifies parameters for prescribing under which evidence and economic analysis demonstrated it to be cost effective.
Future research
The Guideline Committee prioritised the following questions for further research:
What is the clinical and cost effectiveness of mindfulness therapy for managing chronic primary pain in people aged 16 years and over?
What is the clinical and cost effectiveness of cognitive behavioural therapy (CBT) for insomnia or CBT for insomnia and pain for managing chronic primary pain in people aged 16 years and over?
What is the clinical and cost effectiveness of manual therapy for managing chronic primary pain in people aged 16 years and over?
What is the clinical and cost effectiveness of repeat courses of acupuncture or dry needling for managing chronic primary pain in people aged 16 years and over?
What is the clinical and cost effectiveness of gabapentinoids or local anaesthetics for managing complex regional pain syndrome in people aged 16 years and over?
Guidelines into practice
In what proportion of consultations with people with chronic pain has there been a documented discussion about the contributors to and the effects of the pain experience?
How can commissioners ensure everyone with chronic primary pain can access a supervised group exercise programme?
How patients were involved in the creation of this article
Committee members involved in this guideline update included lay members who contributed to the formulation of the recommendations summarised here. One lay member is a co-author of this article.
Further information on the guidance
This guidance was developed by the National Guideline Centre in accordance with NICE guideline development methods (https://www.nice.org.uk/media/default/about/what-we-do/our-programmes/developing-nice-guidelines-the-manual.pdf). A guideline committee was established, which incorporated healthcare professionals and two lay members.
Review questions were developed based on key clinical areas of the scope. Systematic literature searches, critical appraisals, evidence reviews, and evaluations of cost effectiveness, where appropriate, were completed for all review questions. Quality ratings were based on GRADE methodology (www.gradeworkinggroup.org/) for intervention reviews and GRADE CERQual (www.cerqual.org) for qualitative reviews. These relate to the quality of the available evidence for assessed outcomes or certainty of evidence supporting themes rather than the quality of the study. Original economic modelling was undertaken in priority areas not sufficiently addressed by the published cost effectiveness literature.
The scope and draft of the guideline went through a rigorous reviewing process, in which stakeholder organisations were invited to comment; the committee took all comments into consideration when producing the final version of the guideline.
NICE will conduct regular reviews after publication of the guidance, to determine whether the evidence base has progressed significantly enough to alter the current guideline recommendations and require an update.
Acknowledgments
The members of the Guideline Committee were (shown alphabetically): Polly Ashworth, Chris Barker, Ian Bernstein, Diarmuid Denneny, Benjamin Ellis, Jens Foell, Amanda Hendry (until July 2019), Roger Knaggs, Nick Kosky (chair), Candida McCabe, Lucy Ryan, Cathy Stannard (clinical lead), John Tetlow, and Colin Wilkinson.
Footnotes
Contributors: All four authors confirm that they meet all four authorship criteria in the ICMJE Uniform requirements. SC is the guarantor for this article.
Competing interests: Competing interests: Declarations of interests were based on NICE’s policy on conflicts of interests (https://www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/declaration-of-interests-policy.pdf): SC and MC have no declared interests. The guideline authors’ full statements can be viewed at https://www.nice.org.uk/guidance/ng193/documents/register-of-interests-2.
Funding: No authors received specific funding from NICE to write this summary. The guideline referred to in this article was produced by the National Guideline Centre, which received funding from NICE. The views expressed in this article are those of the authors and not necessarily those of NICE.