Managing chronic pain in the non-specialist setting: a new SIGN guideline

CHRONIC PAIN AND THE NEED FOR A GUIDELINE

Chronic pain, defined as pain lasting beyond normal tissue healing time (taken to be 3 months),¹ is a syndrome that affects a large proportion of the primary care population. It is ‘significant’ in around 14% of UK adults, imposing a heavy burden on the physical and psychosocial health of sufferers, their families and society, at high cost to the healthcare services.² It was estimated in 2002 that people with chronic pain account for 4.6 million GP appointments in the UK, at an annual cost to the NHS of £69 million, equivalent to the employment of 793 GPs.³ Although many clinical conditions can lead to chronic pain, there are common underlying neurobiological and psychosocial mechanisms, and the impact is generally independent of the clinical aetiology. Effective assessment and treatment of chronic pain therefore means that GPs should have:

• adequate education and knowledge;

• access to evidence-based effective management strategies; and

• agreed criteria for referral to specialist clinics.

Unfortunately, none of these requirements is generally in place.

Undergraduate training in management of pain is demonstrably minimal, accounting for <1% of programme hours,⁴ despite its high prevalence and impact. Much of the available evidence for potential interventions is derived from specialist settings or in specific clinical conditions, making it difficult to apply to a general primary care population. Even standard treatments, such as drugs, often lack evidence for effectiveness beyond the short or medium term. However, in recent years, there have been some innovations in primary care, and a growing body of evidence for their feasibility and effectiveness. Partly on the strength of this, there are now standard guidelines to support nonspecialist management of some chronic pain conditions, such as low back pain⁵ and neuropathic pain.⁶ There has not been a comprehensive guideline consolidating current knowledge of effectiveness of all interventions for all chronic pain, although this would be valuable in primary care. As Moore et al recently indicated, most people with pain do not respond well to any single intervention, but most will respond to at least one intervention.⁷ Therefore ,the current challenges are to identify the correct intervention(s) for each patient, and to identify and stop ineffective treatments. These will be aided by easily-accessed clinical evidence, informed patient-centred review of our patients, and appropriate referral to colleagues in specialist services.

SIGN

For the past 20 years, the Scottish Intercollegiate Guidelines Network (SIGN) has produced evidence-based guidelines to optimally inform clinical practice, with the aims of reducing variation in service and improving patient outcomes. The methodology and objectivity of SIGN guidelines are internationally recognised and have an influence on healthcare worldwide. Recognising a large area of unmet need, a multidisciplinary SIGN guideline development group produced a new guideline on chronic pain, published in December 2013.⁸ This guideline is specifically aimed at the non-specialist reviewing the assessment and management of adults with chronic non-malignant pain.

IMPLEMENTATION AND NEXT STEPS

This Guideline is relevant internationally, presenting the best available evidence for management of chronic pain by nonspecialists. It is available freely online⁶ and also in a quick reference guide and apps for Apple and Android systems. It therefore has the potential to inform all healthcare practitioners, and will be of particular interest to GPs and primary healthcare teams in the UK. Its implementation will be supported by the NHS in Scotland through linkage with SIGN to all NHS Boards, and through audit tools, linked to performance indicators, and targeted educational events.

This guideline will confirm and support much of the excellent practice that GPs are already providing for chronic pain in primary care. It will also provide a useful summary for those who are trying to find a way through the complex multimodal maze, which has so far been beset with conflicting evidence and advice. It will potentially highlight the importance of multidimensional and multi-discplinary approaches to chronic pain, and the need for continuing education and training in this area (as well as increased resource provision).

Finally, perhaps the most important finding in the guideline development process, of longer-term relevance, is the relative lack of good quality evidence available and applicable in primary care. This includes both standard approaches to treatment (for example, long-term opioids) and more innovative approaches (for example, self-management programmes). Therefore, there is an urgent need to commission and conduct primary care-based trials, recognising the need for psychological and physical therapy, considering the potential role of education, advice and complementary approaches, and the methodological complexities of identifying and measuring timely, relevant outcomes. This will allow an enhanced second edition of this Guideline when it is considered for review in 3 years’ time.