NICE chronic primary pain guidelines: what the busy GP needs to know

Adam Harvey-Sullivan; Sally Higginbottom; Thomas Round

doi:10.3399/bjgp22X719453

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Acupuncture for chronic primary pain
Elen Williams

Published on: 06 May 2022
NICE chronic primary pain guidelines: Is the busy GP being properly informed?
Marion Brown

Published on: 05 May 2022

Published on: (6 May 2022)
Page navigation anchor for Acupuncture for chronic primary pain
Acupuncture for chronic primary pain
Elen Williams, GP, Locum.
In relation to “no more than five sessions” of acupuncture stated in this article, it should be clarified that acupuncture delivery, as per the NICE guidelines for chronic primary pain, is specified as no more than five hours of healthcare professional time. The number and length of sessions can be adapted within these boundaries. This would allow for ten 30-minute sessions, which is the typical number of sessions delivered to a patient with chronic pain.

Recently, I have been delivering an acupuncture service at a GP practice in East London. To facilitate maximum time efficiency – the patient rests in one consultation room with the acupuncture needles in situ for 20-30 minutes, whilst I use another room for telephone consultations or admin. The actual time I spend with the patient administering an acupuncture treatment is around 10-15 minutes per session.

Competing Interests: Member of British Medical Acupuncture Society.
Published on: (5 May 2022)
Page navigation anchor for NICE chronic primary pain guidelines: Is the busy GP being properly informed?
NICE chronic primary pain guidelines: Is the busy GP being properly informed?
Marion Brown, Retired, none
It is confirmed in this ‘need to know’ article¹ that ‘the busy GP’ will undoubtedly be confused by the 2021 NICE chronic primary pain guidelines:

• The questionable effectiveness and suitability of alternatives in this context (given as exercise, cognitive behaviour therapy (CBT), acceptance and commitment therapy (ACT))
• The non-recommendation for ‘social-prescribing’ – and just limited acupuncture.
• No recommended analgesic prescribing
• ‘The busy GP’ will likely be bamboozled by complications of ‘review and deprescribing’ - the NICE guideline “does not provide any guidance about how to do this in the context of potentially prolonged polypharmacy...”
• So… most ‘busy GPs’ will of course opt for the ‘NICE recommended’ prescribing of antidepressants - especially with the astonishingly worded NICE ‘reassurance’ that “there is evidence of benefit in improving quality of life, pain, sleep, and psychological distress… This includes those without a concomitant diagnosis of depression, although this is an off-label use.” And the specific recommendation for Duloxetine! Duloxetine is known to carry ‘high risk’ of dependence and withdrawal problems as per the Royal College of Psychiatry’s information on ‘stopping antidepressant...
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It is confirmed in this ‘need to know’ article¹ that ‘the busy GP’ will undoubtedly be confused by the 2021 NICE chronic primary pain guidelines:

• The questionable effectiveness and suitability of alternatives in this context (given as exercise, cognitive behaviour therapy (CBT), acceptance and commitment therapy (ACT))
• The non-recommendation for ‘social-prescribing’ – and just limited acupuncture.
• No recommended analgesic prescribing
• ‘The busy GP’ will likely be bamboozled by complications of ‘review and deprescribing’ - the NICE guideline “does not provide any guidance about how to do this in the context of potentially prolonged polypharmacy...”
• So… most ‘busy GPs’ will of course opt for the ‘NICE recommended’ prescribing of antidepressants - especially with the astonishingly worded NICE ‘reassurance’ that “there is evidence of benefit in improving quality of life, pain, sleep, and psychological distress… This includes those without a concomitant diagnosis of depression, although this is an off-label use.” And the specific recommendation for Duloxetine! Duloxetine is known to carry ‘high risk’ of dependence and withdrawal problems as per the Royal College of Psychiatry’s information on ‘stopping antidepressants’.²

The problems with this last ‘recommendation’ (antidepressants) were pointed out in BJGP Journal ‘Life and Times’ article July 2021: “New NICE guideline: antidepressants and chronic pain – chicken or egg?”³ “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 (antidepressants), 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.”

Much new work has been published revealing the ever-growing extent of the too-long-overlooked/unrecognised antidepressant problems - for patients and prescribers … and indeed for prescribers who are also patients (including Horowitz & Taylor 2022, “Distinguishing relapse from antidepressant withdrawal”)⁴ and also books by Michael Hengartner “Evidence-biased antidepressant prescribing”,⁵Beverley Thomson “Antidepressed”,⁶ Giovanni Fava, Peter Gotzsche and others.

This is deeply perplexing. Surely practising GPs need better informed Essential Knowledge Updates and e-learning support in order to minimise risks of further unintended harm to patients?

References

1. Harvey-Sullivan A, Higginbottom S, Round T. NICE chronic primary pain guidelines: what the busy GP needs to know. Br J Gen Pract 2022; 72(718): 240-241. DOI: 10.3399/bjgp22X719453.
2. Burn W, Horowitz M A, Roycroft G, et al. (2020) Stopping Antidepressants. Royal College of Psychiatrists. www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/stopping-antidepressants.
3. Brown M. New NICE guideline: antidepressants and chronic pain — chicken or egg? Br J Gen Pract 2021; 71(708): 320. DOI: 10.3399/bjgp21X716345
4. Horowitz M, & Taylor D. Distinguishing relapse from antidepressant withdrawal: Clinical practice and antidepressant discontinuation studies. BJPsych Advances 2022, 1-15. doi:10.1192/bja.2021.62.
5. Hengartner M. Evidence-biased antidepressant prescribing. 2021 Springer ISBN: 978-3-030-82587-4.
6. Thomson B. Antidepressed. 2022 Hatherleigh press. ISBN 9781578269235.

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Competing Interests: None declared.