Drugs for chronic pain

Christina Abdel Shaheed; Gustavo C Machado; Martin Underwood

doi:10.3399/bjgp20X713549

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In August 2020, the National Institute for Health and Care Excellence (NICE) published the draft guidance on chronic pain, which perhaps controversially advises against the use of all drugs except antidepressants.¹ The committee cite an absence of evidence on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 class	Draft NICE guideline: chronic pain in over 16s, August 2020¹	NICE guideline: low back pain and sciatica in over 16s, updated September 2020⁵	NICE guideline: headache in over 12s, updated November 2015⁴^,a	NICE guideline: irritable bowel syndrome in adults, updated April 2017⁶	NICE guideline: osteoarthritis, updated February 2014⁸
Opioids	Do not offer	Do not offer	Be 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 recommendation	If paracetamol or topical NSAIDs are insufficient consider the addition of opioid analgesics
NSAIDs	Do not offer	Consider oral NSAIDs (conditions apply)		No specific recommendation	Where paracetamol or topical NSAIDs are ineffective consider substitution with (or addition of) an oral NSAID/COX-2 inhibitor
Paracetamol (acetaminophen)	Do not offer	Do not offer paracetamol alone		No specific recommendation	Consider offering paracetamol in addition to core treatments.
Antidepressants	Consider an antidepressant, either duloxetine, fluoxetine, paroxetine, citalopram, sertraline, or amitriptyline	Do not offer SSRIs, serotonin–norepinephrine reuptake inhibitors, or tricyclic antidepressants	Consider amitriptyline for the prophylactic treatment of migraine	Consider TCAs as second line treatment for people with IBS. Consider SSRIs for people with IBS only if TCAs are ineffective	No specific recommendation
Anticonvulsants	Do not offer	Do not offer	Do not offer gabapentin for prophylactic management of migraine	No specific recommendation	No 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