NICE summary guidance - management of chronic pain

Last edited 05/2021 and last reviewed 05/2023

NICE guidance summary - chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain

• chronic pain (sometimes known as long-term pain or persistent pain) is pain that lasts for more than 3 months
• pain can be secondary to (caused by) an underlying condition (for example, osteoarthritis, rheumatoid arthritis, ulcerative colitis, endometriosis)
• primary
  • chronic primary pain has no clear underlying condition or the pain (or its impact) appears to be out of proportion to any observable injury or disease
• chronic primary pain and chronic secondary pain can coexist
  
  
• ICD-11 gives examples of chronic primary pain, including:
  • fibromyalgia (chronic widespread pain),
  • complex regional pain syndrome,
  • chronic primary headache and orofacial pain,
  • chronic primary visceral pain
  • chronic primary musculoskeletal pain
• UK prevalence of chronic pain is uncertain
  • appears common, affecting perhaps one-third to one-half of the population in their lifetime
  • prevalence of chronic primary pain is unknown, but is estimated to be between 1% and 6% in England.

Considerations when diagnosing chronic primary 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 primary pain may change with time. Re-evaluate the diagnosis if the presentation changes
• recognise that chronic primary pain can coexist with chronic secondary pain

Considerations if Flare-ups of chronic pain

• offer a reassessment if a person presents with a change in symptoms such as a flare-up of chronic pain. Be aware that a cause for the flare-up may not be identified
• if a person has a flare-up of chronic pain:
  • review the care and support plan
  • consider investigating and managing any new symptoms
  • discuss what might have contributed to the flare-up

Management

• non-phamacogical options for management of chronic primary pain
  • exercise programmes and physical activity for chronic primary pain
    • 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
    • encourage people with chronic primary pain to remain physically active for longer-term general health benefits
  • Psychological therapy for chronic primary pain
    • consider acceptance and commitment therapy (ACT) or cognitive behavioural therapy (CBT) for pain for people aged 16 years and over with chronic primary pain, delivered by healthcare professionals with appropriate training
    • do not offer biofeedback to people aged 16 years and over to manage chronic primary pain
  • Acupuncture for chronic primary pain
    • 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 band 7 (equivalent or lower) healthcare professional 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
        
        
• Pharmacological management of chronic primary pain
  • 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
  • seek specialist advice if pharmacological management with antidepressants is being considered for young people aged 16 to 17 years
  • 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
  • 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 the recommendation for research on pharmacological interventions)
    • 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 the recommendation for research on pharmacological interventions)
    • local anaesthetic/corticosteroid combination trigger point injections
    • non-steroidal anti-inflammatory drugs
    • opioids
    • paracetamol
      
      
    • if a person with chronic primary pain is already taking any of the medicines listed as not appropriate to initiate in chronic pain, then 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.
  • Pregabalin and gabapentin (gabapentinoids) are Class C controlled substances (under the Misuse of Drugs Act 1971) and scheduled under the Misuse of Drugs Regulations 2001 as Schedule 3. Evaluate patients carefully for a history of drug misuse before prescribing and observe patients for development of signs of misuse and dependence (MHRA Drug Safety Update April 2019)
  • when making shared decisions about whether to stop antidepressants, opioids, gabapentinoids or benzodiazepines, discuss with the person any problems associated with withdrawal
  • for recommendations on stopping or reducing antidepressants, see the NICE guideline on depression in adults

For details then consult full NICE guidance.

Reference:

• NICE (April 7th 2021). Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain