Painkillers such as paracetamol, ibuprofen, aspirin and opioids can do “more harm than good” and should not be prescribed to treat chronic pain, health officials have said.
Draft guidance from the National Institute for Health and Care Excellence (Nice) said that there was “little or no evidence” the commonly used drugs for chronic primary pain made any difference to people’s quality of life, pain or psychological distress.
But the draft guidance, published on Monday, said there was evidence they can cause harm, including addiction.
Chairman of the guidance committee Nick Kosky said that, while patients expected a clear diagnosis and effective treatment, the complexity of the condition means GPs and specialists can find it very “challenging” to manage.
The consultant psychiatrist at Dorset HealthCare NHS University Foundation Trust added: “This mismatch between patient expectations and treatment outcomes can affect the relationship between healthcare professionals and patients, a possible consequence of which is the prescribing of ineffective but harmful drugs.
“This guideline, by fostering a clearer understanding of the evidence for the effectiveness of chronic pain treatments, will help to improve the confidence of healthcare professionals in their conversations with patients.
“In doing so it will help them better manage both their own and their patients’ expectations.”
Chronic primary pain is a condition in itself which cannot be accounted for by another diagnosis or as a symptom of an underlying condition, Nice said.
It is characterised by significant emotional distress and functional disability with examples including chronic widespread pain and chronic musculoskeletal pain, it added.
Nice said an estimated third to half of the population may be affected by chronic pain while almost half of people with the condition have a diagnosis of depression and two-thirds are unable to work because of it.
The draft guidance, which is open to public consultation until August 14, said that people with the condition should be offered supervised group exercise programmes, some types of psychological therapy, or acupuncture.
It also recommends that some antidepressants can be considered for people with chronic primary pain.
But it said that paracetamol, non-steroidal anti-inflammatory drugs such as aspirin and ibuprofen, benzodiazepines or opioids should not be offered because there was little or no evidence that they made any difference to people’s quality of life, pain or psychological distress.
There was evidence that they can cause harm, including possible addiction, it added.
The draft guideline also said that antiepileptic drugs including gabapentinoids, local anaesthetics, ketamine, corticosteroids and antipsychotics should not be offered to people to manage chronic primary pain because, again, there was little or no evidence that these treatments work but could have possible harms.
Paul Chrisp, director of the centre for guidelines at Nice, said: “”When many treatments are ineffective or not well tolerated, it is important to get an understanding of how pain is affecting a person’s life and those around them because knowing what is important to the person is the first step in developing an effective care plan.
“Importantly the draft guideline also acknowledges the need for further research across the range of possible treatment options, reflecting both the lack of evidence in this area and the need to provide further choice for people with the condition.”
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RecoveringH
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When I trained as a nurse, pain was defined as, something the sufferer experiences to the degree that they define, and that no one else can know what that feels like.
I'd welcome any research into chronic pain. Anecdotally often people will report that the pain relief is ineffective for chronic pain.
Some chronic pain, as in fibromyalgia is difficult to treat, but to deny treatment could be seen as cruel and unnecessary.
There is a psychological element to pain, hence different tolerance levels, but this can feed from what was relief of an acute pain, to anxiety of withdraw of treatment.
Ok, benzos, opioids, antipsychotics, antiepileptics, and even antidepressants can build a physical dependence, with extreme reactions if withdrawn abruptly.
Inadequate pain management can lead to self medication, leading to overdose, or the use of off prescription drugs (elicit, or internet purchase).
The problem with chronic pain, if inadequately addressed there is a risk of just increasing doses to the maximal level, which leaves the need to step up to stronger solutions.
Any medication can be harmful if used long term. I used to wonder how people who overdosed on paracetamol always knew the exact amount the had taken. It is the quantity that they can be bought in, 16 or multiples there of.
But paracetamol used correctly is relatively safe, but oral preparations have limits to their effectiveness.
Something that I think should be better regulated are NSAID, especially the way they are marketed, this can lead to confusion if someone takes from one packet for period pain, and then takes one marketed for head aches, leading to overdose.
Ibrufen has been licenced for general sales for some time, but now diclophenic is available. Long term use of NSAIDs can increase the risk of stroke and other circulatory problems.
Also NSAIDs and the simple aspirin can damage the stomach.
I agree further research is needed, but leaving people in pain is not an option. Better education around pain relief to the general populous is required. But we have a legacy of people who have been on certain medications for protracted time that need help to reduce use, but there needs to be more responsible prescribing, to prevent more people ending on the same path.
To finish where I started, no one can define the pain someone else is experiencing or to what degree.
I can only speak from my personal experience about pain management.
Over the years I have been on many forms of pain relief for chronic back, leg and head pain.
Currently ( and yes for a long time) I have been on the dreaded tramadol.
The amounts have varied over the years but for the last few years I have been on a minimum effective dose . Yes when flare ups occur my dosage goes up.
This minimum dosage I will admit does not alleviate my pain but allows me to move around and keep some form of normal life. Along with a healthy diet and keeping moving seem to be the key to my major pain regime.
I have tried to go medication free and although I had no withdrawal symptoms my chronic pain became unbearable and limited my movement.
I see the role of my medication as being part of my pain management and not the whole thing.
This may be an over simplistic view and like I say is only my experience.
So in short medication I feel does have a place in pain management but alongside other things.
Very much agreed! Also chronic back pain,also on Tramadol, also use it as part of my pain management (but an irreplaceable part - w/out it the spasms are unlivable).
I hate telling people I'm on Tramadol . It usually starts me having to listen to a lecture about how I MUST be addicted to it by now and i will be getting no actual benefits.
I listen quietly until they have finished be fore asking " how long they had been on them and how do they manage pain now"
They usually look at me horrified saying they have never taken it and dont have chronic pain.
I usually add " lucky you"
Like i have said medication is personal. All i would add is be in charge of your medication and not let tyour medication run your life.
I do have reservations about prescribing antidepressants for lower back pain as an example. My doctor did this and they made me feel truly awful. The doctors dismiss osteopaths as quacks, but I find good osteopaths to be very effective. A friend of mine was prescribed antipsychotics for poor sleep and that led down a very slippery slope to life changing effects. Doctors are often pushed for time and looking for a quick fix. Patients going to a doctor put their trust in that person, sometimes too easily. It is a complex issue that should be given better consideration. I am concerned that big pharma may be able to pull too many strings.
I have several herniations and a displaced sciatic nerve root and was on oramorph, tramadol and gabapentin but this was barely touching the pain. I actually thought my thinking and functioning were caused by these. I was diagnosed after this with pernicious anaemia and realised I'd had this for decades undiagnosed/untreated and had been having Nitrous Oxide at the dentist which I learned has caused sub acute combined degeneration of the cord (sacd), and later lesions were found in my frontal sub cortex. Anyway, I started B12 injections daily and realised my pain was improving. I found out B12 injections have been found to be an effective pain treatment and within 2m my pain was sufficiently controlled enough to stop all medication. I was directed to this study europeanreview.org/wp/wp-co... and this one europepmc.org/article/med/3...
There is a place for hospital medicine and there is a place for nutraceuticals (they have renamed nutrition in an attempt to control the entirety of the pharmacy industry). Vitamins replacement was my road to recovery. I had B12 blood infusions which carried their own risks but did shift the healing mechanism into gear. A BI can drain the body of B vitamins which run the nervous system. Glad to hear you were able to stop all meds.
Continued medication use can dry out the gut flora reducing immunity and taking control of the body's innate ability to heal itself. Vitamins, herbs, supplements, foods as medicine, all contribute to a rebalancing of immunity. Adding and not taking away. Mainstream medicines mostly come with side effects.
What irks me is that while sitting with a 'trusted' person, the meds route is always the first consideration when it undoubtedly would benefit the NHS, the population and doctor patient relationships if it was the other way around. What nutritional deficiencies do you have? Ok we cant solve that, we will put you on some medicine to see if that helps.
If you consider the research around vitamin deficiency correlation with the top 3 killers in the UK you have your evidence for a change in approach. The top three killers each year are cancer, dementia/alzheimers, and heart disease - totalling 271,830 deaths in 2018. Every BI takes a hit on the nerves. Vitamin B test should be the very first test after a BI. Prolonged vit B deficiency leads to all sorts of other issues related to iron, hormones, lymph and in time circulation, muscles and heart.
I've been a member of 2 very knowledgeable support groups and never heard of BI depleting B12 - do you have any medical studies relating to this? I think you misunderstand me a bit about pernicious anaemia. It's an autoimmune condition that destroys intrinsic factor which is essential for the absorption of B12. Without treatment it's a potentially fatal demyelinating condition. Nitrous oxide oxidises all B12 rendering it inactive - this is ok if you can absorb it from food but extremely dangerous if you have undiagnosed pernicious anaemia - this is how my BI occurred. I don't actually favour infusion as a means of delivery as it's quite ineffective compared to regular IM or even subcutaneous injections. I need injections of B12 for life if I am to survive. If you are able to absorb B12 from food you are also able to access a store in your liver that can last between 3-5 years so becoming deficient that way is difficult and involves having a strict vegan diet without supplementing or having fortified foods for a long time.
The BI recovery process depletes vitamin B's which facilitate a healthy nervous system function. Put simply, the body uses up more vit B as it is stressed, because it is malfunctioning.
Research for B12 and TBI recovery
Vitamin B12 Enhances Nerve Repair and Improves Functional Recovery After Traumatic Brain Injury by Inhibiting ER Stress-Induced Neuron Injury
My family history has pernicious anaemia. It is the reason why I opted for the B12. I made great progress taking Betaine & Pepsin after reading this article
As for why I opted for infusions, I had B12 alongside ozone (ozone used in Germany as mainstream meds) so it worked fantastically well in a short period.
For the last 8 years, I have had varying amounts of iron deficiency anemia but after following a ferritin course and taking regular iodine, it seems to have righted itself. I have changed my diet to simplify foods mixed together in any one meal, used high amounts of black pepper as my acid, removed all unnatural sugar sources and enjoy a healthy diet now with good energy to run and walk.
Gotcha, yes, stress (physical and emotional) deplete B12 as well as exercise and some drugs (alcohol particularly) although this should not be a problem unless you are early in treating B12d.
Since you have a family history of malabsorption you need to test B12 regularly but to do this you must be at least 4 months clear of having any B12 supplement, including in fortified foodstuffs like energy drinks and meal replacement shakes. All B12 tests are skewed by supplements, which is a very dangerous state of affairs since doctors who are knowledgeable about B12d are as rare as hens teeth and few understand that supplements skew serum tests for such a long time and often accept a 'normal' haematology reading at face value. This can mean you may be left undiagnosed and untreated for this potentially fatal demyelinating condition! Only regular injections can treat an inability to absorb and although supplements raise serum levels you will still deteriorate.
B12 and folate are cofactors ie dependant on each other so if you are on regular lifelong injections you need your folate level to stay in the top 3rd of the range or you will be unable to use the B12.
B12d raises homocysteine which in turn can cause cardiovascular problems, which with a BI we need to avoid.
I also take a B complex but no more than 10mg B6 which is the only B vitamin that can become a neurotoxin at higher levels. Symptoms of B6 toxicity are very similar to B12d.
Of course since the majority of people are deficient in vitamin D I take that along with it's cofactor K2mk7 to ensure calcium goes into bones and teeth not trapped in serum where it can cause problems.
This is only for chronic pain though? I had antiepileptics for many years but the cause of the pain was known. I never understood why or how antiepileptics work for pain management. My new GP since I moved seems to have no knowledge of brain injury and claims to have never heard of anti epilepsy drugs being used as pain management.
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