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Editorials

Drugs for chronic pain

Christina Abdel Shaheed, Gustavo C Machado and Martin Underwood
British Journal of General Practice 2020; 70 (701): 576-577. DOI: https://doi.org/10.3399/bjgp20X713549
Christina Abdel Shaheed
Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District; Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
Roles: Academic Fellow
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Gustavo C Machado
Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District; Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
Roles: National Health and Medical Research Council Early Career Research Fellow
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Martin Underwood
Warwick Clinical Trials Unit, University of Warwick; University Hospitals Coventry and Warwickshire, Coventry, UK.
Roles: Professor of Primary Care Research
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INTRODUCTION

In August 2020, the National Institute for Health and Care Excellence (NICE) published the draft guidance on chronic pain, which perhaps controversially advises against the use of all drugs except antidepressants.1 The committee cite an absence of evidence on effectiveness, their experience, information in product summaries, and the established or possible risk of harm as justification for their negative recommendations. Public reaction perhaps reflects the assumption the guidelines apply to all chronic pain conditions. This is not the case. The guideline explicitly does not cover pain conditions that have existing NICE guidelines including headache, low back pain (LBP) and irritable bowel syndrome (IBS).1–6 This creates an interesting tension, since some recommendations are discordant (Box 1).

Drug classDraft NICE guideline: chronic pain in over 16s, August 20201NICE guideline: low back pain and sciatica in over 16s, updated September 20205NICE guideline: headache in over 12s, updated November 20154,aNICE guideline: irritable bowel syndrome in adults, updated April 20176NICE guideline: osteoarthritis, updated February 20148
OpioidsDo not offerDo not offerBe alert to the possibility of medication overuse headache in people whose headache developed or worsened while they were taking the following drugs for ≥3 months:
  • opioids, on 10 days per month or more; or

  • paracetamol, aspirin, or an NSAID, either alone or in any combination, on 15 days per month or more

No specific recommendationIf paracetamol or topical NSAIDs are insufficient consider the addition of opioid analgesics
NSAIDsDo not offerConsider oral NSAIDs (conditions apply)No specific recommendationWhere paracetamol or topical NSAIDs are ineffective consider substitution with (or addition of) an oral NSAID/COX-2 inhibitor
Paracetamol (acetaminophen)Do not offerDo not offer paracetamol aloneNo specific recommendationConsider offering paracetamol in addition to core treatments.
AntidepressantsConsider an antidepressant, either duloxetine, fluoxetine, paroxetine, citalopram, sertraline, or amitriptylineDo not offer SSRIs, serotonin–norepinephrine reuptake inhibitors, or tricyclic antidepressantsConsider amitriptyline for the prophylactic treatment of migraineConsider TCAs as second line treatment for people with IBS. Consider SSRIs for people with IBS only if TCAs are ineffectiveNo specific recommendation
AnticonvulsantsDo not offerDo not offerDo not offer gabapentin for prophylactic management of migraineNo specific recommendationNo specific recommendation
  • ↵a The guidance for headache is not specific to chronic headache pain. NSAIDs and paracetamol are recommended for acute treatment of tension headache and migraine with or without aura. IBS = iritable bowel syndrome. NICE = National Institute for Health and Care Excellence. NSAID = non-steroidal anti-inflammatory drug. SSRI = selective serotonin reuptake inhibitor. TCA = tricyclic antidepressants.

Box 1.

Concordance between drug recommendations in draft NICE chronic pain guideline and NICE guidelines for low back pain, headache, irritable bowel syndrome, and osteoarthritis

SUMMARY

The guideline committee used the International Classification …

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British Journal of General Practice: 70 (701)
British Journal of General Practice
Vol. 70, Issue 701
December 2020
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Drugs for chronic pain
Christina Abdel Shaheed, Gustavo C Machado, Martin Underwood
British Journal of General Practice 2020; 70 (701): 576-577. DOI: 10.3399/bjgp20X713549

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Drugs for chronic pain
Christina Abdel Shaheed, Gustavo C Machado, Martin Underwood
British Journal of General Practice 2020; 70 (701): 576-577. DOI: 10.3399/bjgp20X713549
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