Chronic pain is debilitating and depressing. ‘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.’1
In July 2014, Sir Simon Wessely stated in an article in The Times entitled, Pain may be in the mind, that: ‘Many of them [chronic pain patients] have mental health disorders — anxiety, depression, etc’, and that, ‘patients felt dismissed and denigrated when they were referred to mental health services … ’.2
As patient safety campaigners, we are hearing from many people who are developing ‘unexplained’ chronic pain conditions after taking antidepressants (ADs), as prescribed, and sometimes over many years — and this has often led to polypharmacy with other drugs added ‘for symptoms’ along the way, most likely including ADs, benzodiazepines, Z-drugs, opioids, and/or gabapentinoids. These are the five classes of drugs included in the Public Health England (PHE) review of dependence and withdrawal associated with some prescribed medicines, which reported in September 2019.3
LAYERS OF COMPLEX DEPENDENCY
Of course, all of these drugs add more layers of dependency, and other side effects and adverse effects — as well as (now slightly better recognised) complex withdrawal problems. Building on the work of others already raising concerns for many years, we have ourselves been campaigning, especially about the issues of the adverse effects of commonly-prescribed ADs, and also benzodiazepines, since 2014. This is summarised in our BMJ response, Is the BMJ — and the medical profession that it represents — really “listening to patients” and the public?, in April 2018.4 Following this, in October 2018 we prepared and published our own systemic research with the Westminster All-Party Parliamentary Group for Prescribed Drug Dependence (APPG-PDD) (http://prescribeddrug.org/wp-content/uploads/2015/10/Voice-ofthe-Patient-Petition-Analysis-Report-forpublication-081018.pdf), drawing directly on the detailed written evidence submitted for our 2017 Scottish and Welsh public petitions. This was accepted and analysed (together with further patient experience evidence) within the National Guideline Centre’s Patient’s experience: review of the evidence 2019 publication,5 and was included in section 4 on patients’ experiences of harms in the PHE review of 2019.3
In late 2020 an expanded version of our work with the APPG-PDD was formally published by Therapeutic Advances in Psychopharmacology, with a specific focus on how AD and withdrawal effects are frequently missed or misdiagnosed. This aspect has since been further explored in our article.6
In this context, we were stunned to read the statement on 6 April 2021 by the National Institute for Health and Care Excellence (NICE)1 that: ‘The antidepressants amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine, or sertraline are the only drug treatments that should be offered to patients with chronic primary pain because evidence shows these may improve quality of life, pain, sleep, and psychological distress, even in the absence of depression’, and that, ‘For many commonly prescribed drugs, including paracetamol, non-steroidal anti-inflammatory drugs, benzodiazepines, or opioids, there is little or no evidence that they make any difference to people’s quality of life, pain, or psychological distress, but they can cause harm, including possible addiction.’
So, what the new NICE guideline suggests is that people will be called for review of their medications and recommended to be withdrawn from the ‘addictive’ medicines — and that ‘non-addictive’ ADs will be the only pharmacological option ‘recommended’. This scenario is fraught with problems. Deprescribing of polypharmacy is complex — and in any case the same people will very likely already be taking prescribed ADs, and already be suffering from various adverse effects of these, effects that may indeed have led on to the chronic pain conditions that resulted in polypharmacy. As quoted in The Times article, Sir Simon Wessely and his associates are always keen to attribute everything to people’s ‘depression’ and ‘anxiety’, and to treat with ADs. There have been many concerns raised about ADs, which seem in this new primary chronic pain guidance1 to be completely overlooked by NICE, once again.
Could it be that the ADs are the problem, as detailed by John Warren in his 2020 essay, The trouble with antidepressants: why the evidence overplays benefits and underplays risks?7
- © British Journal of General Practice 2021
