How Can GPs Navigate the Complexities of Chronic Pain Management?

Dr Anish Kotecha Revisits the NICE Guideline on Chronic Pain, Exploring the Benefits and Challenges of its Implementation in Everyday Practice

Chronic pain—broadly defined as pain persisting or recurring for more than 3 months¹—is a multifaceted challenge for medical practitioners and patients. It can affect one or more anatomical areas, and is associated with significant functional disability and emotional distress: an estimated 48% of people with chronic pain have depression, and the co-occurrence of other mental health conditions such as anxiety is also common.^1,2 The socioeconomic implications of chronic pain are equally daunting, with many people facing job loss, strained personal relationships, and financial hardship.² 

Chronic pain is a pervasive issue. In the UK alone, studies estimate that between one-third and half of the population is living with some form of chronic pain.^1,3 Chronic primary pain in particular—that is, chronic pain with no clear underlying cause—is estimated to affect 1–6% of adults in England.¹ 

NICE Guideline (NG) 193, Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain, was published in April 2021,¹ and elicited a wide range of reactions from both patients and clinicians.^4–7 Some expressed reservations, particularly about the guideline’s cautious stance on medication for chronic primary pain and the resulting potential for undertreatment.^5–7 Conversely, NG193 received praise for adopting a holistic, patient-centred approach that prioritises shared decision-making and active patient involvement in treatment, as well as for acknowledging the subjective nature of pain;^4–7 at the time of publication, this was the first time that chronic primary pain had been recognised by NICE as a standalone condition.^1,6

An estimated 70% of people with chronic pain are managed in primary care,⁸ so it is particularly important that primary care practitioners are aware of the benefits and limitations of NG193’s approach to chronic pain. This article discusses the guidance in depth.

Definitions of Chronic Pain

Chronic pain is broadly defined as pain that persists or recurs for 3 months or more, and can be separated into:¹

• chronic primary pain—in which the pain has no clear underlying cause, or the pain and its impact are disproportionate to any observable condition; examples include chronic primary musculoskeletal pain, chronic primary headache, chronic primary visceral pain, complex regional pain syndrome, and fibromyalgia
• chronic secondary pain—in which the pain is attributed to a specific condition; examples include rheumatoid arthritis, osteoarthritis, endometriosis, or nerve damage. 

Although the guidance acknowledges that these two types of chronic pain can coexist, the distinction between them is important, as it dictates the therapeutic approach.¹

In using these definitions, NICE is basing NG193’s recommendations on the diagnostic criteria of the 11^th revision of the World Health Organization’s International classification of diseases (ICD-11), which was published in 2019 and came into effect in January 2022 (see Box 1).^1,9,10 The broad definition of chronic primary pain brings a number of conditions within the remit of the guideline, as the ICD-11’s umbrella term ‘chronic primary pain’ is comprised of various subcategories.^1,7,9 Although this wide definition may have benefits for the guideline’s scope and interpretation, it is a cause for concern to some—notably, the Faculty of Pain Medicine (FPM) of the Royal College of Anaesthetists (RCA), which criticised NICE for not acknowledging important differences between diagnoses as distinct as fibromyalgia and chronic primary headache.⁷

The Role of Primary Care in Assessment and Management

NG193’s recommended approach to the assessment and management of chronic pain is summarised in Figure 1.^1,11

Figure 1: Chronic Pain (Primary and Secondary)—Using NICE Guidelines for Assessment and Management¹¹

Holistic Assessment and Care Plans

In primary care, assessment is the cornerstone of effective pain management. Beyond gauging physical symptoms, primary care clinicians should develop an understanding of how their patient’s pain impacts—and is impacted by—various aspects of their life, including their psychological wellbeing, socioeconomic status, social relationships, and overall quality of life.¹ This holistic understanding offers invaluable insights that will help a clinician to individualise their therapeutic approach and develop a care and support plan with their patient.¹

A patient’s care and support plan should be tailored to their unique needs and adaptable to changing symptoms and circumstances.¹ Regular reviews are recommended to ensure a plan’s continued relevance and efficacy, and are particularly useful when a person experiences a flare-up of their symptoms.¹ Crucially, patients should play an active role in shaping this plan, and clinicians should ensure that the patient’s needs and preferences are the priority.¹ A useful care and support plan will take into account the patient’s present situation, including their current abilities, preferred approach to treatment, and anything that is already helping them to manage; it will also take the future into account, including consideration of priorities and goals, strategies for flare-ups, and any possible support the patient may need in future.¹

Nonpharmacological Management of Chronic Primary Pain

NG193’s section on management is exclusively for patients with chronic primary pain.¹ For managing chronic secondary pain, the guidance signposts clinicians to the relevant NICE guidance on the underlying chronic pain condition (such as headache or osteoarthritis).¹ The pharmacological recommendations in this area of the guideline are its most controversial aspect, and are covered in the section How was the Guideline Received?, below.

NG193 primarily recommends nonpharmacological options for managing chronic primary pain (see Figure 1).¹ These options include:¹

• a supervised group exercise programme, with consideration of individual needs, preferences, and abilities
• acceptance and commitment therapy or cognitive behavioural therapy
• a single course of acupuncture or dry needling, delivered in a community setting by a healthcare professional with appropriate training.

The guideline stresses that biofeedback, ultrasound, interferential therapy, and transcutaneous electrical stimulation therapy should not be offered, as there is no evidence of any benefit.¹

In my experience, effective pain management demands a multifaceted strategy: although medications are a key component, nonpharmacological interventions—such as physical therapy, counselling, or lifestyle modifications—are equally important. In this regard, the guideline ultimately recommends a balanced approach, involving comprehensive care that addresses the patient’s physical, psychological, and socioeconomic needs.

How was the Guideline Received?

The key potential issues relating to NG193, raised by several independent professional bodies, are detailed in Box 2.^5–7 Most notably, the guideline’s cautious approach to certain medications, although well intentioned, has sparked debate among medical professionals specialising in chronic pain, many of whom have raised concerns that patients will be undertreated as a result of these recommendations, and will not receive adequate pain relief.^4–7 The debate underscores what is, in my opinion, the key issue in managing chronic pain: the delicate balance between minimising medication risks on one hand, and ensuring effective pain management on the other.

Pharmacological Management

For the pharmacological treatment of chronic primary pain, the guideline exclusively recommends the use of antidepressants for individuals aged 18 years and over, specifically amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine, or sertraline.¹ As NICE explains, this is because there is evidence that antidepressants improve pain, sleep, psychological distress, and quality of life for people with chronic primary pain.^1,12 NG193’s Guideline Development Group (GDG) did acknowledge limitations in this evidence—for example, duloxetine is the only serotonin–norepinephrine reuptake inhibitor with evidence for chronic primary pain, and most of the evidence was specific to women with fibromyalgia—and consequently recommended specific antidepressants for which there is evidence of benefit.¹ 

However, the guideline recommends that clinicians do not initiate the following medicines for the management of chronic primary pain:¹

• antiepileptic drugs (including gabapentinoids)
• antipsychotic drugs
• benzodiazepines
• corticosteroid injections and combination injections of local anaesthetic and corticosteroids
• ketamine
• nonsteroidal anti-inflammatory drugs (NSAIDs)
• opioids
• paracetamol.

If a person with chronic primary pain is taking any of these medications, the guidance recommends that they should have a review in which a clinician explains the lack of evidence about the medication’s effectiveness, with a view to reducing the dose or stopping the medication if they report little benefit or significant harm.¹ If the patient is using a safe dose and gaining benefit from it, with few harms, a shared plan to continue safely should be agreed.¹ Explaining these recommendations, NICE stresses that the evidence—especially with regard to gabapentinoids, opioids, and benzodiazepines—suggests a lack of benefit for these medications, but more importantly highlights that they carry risks of harm, such as through misuse, addiction, and dependence.^1,12

With pharmacotherapy, therefore—an area in which evidence is lacking—it appears that NICE is erring on the side of caution and making more limited, evidence-based recommendations, whereas many practitioners who manage patients with chronic pain in their daily practice are critical of this approach and advocate for personalised patient care that may involve the use of medications associated with greater risk. It is certainly a difficult line to walk. GPs have always been valued for their ability to make pragmatic decisions and build a therapeutic relationship with their patients. However, it may be difficult for them to interact with their patient in a consultation room and help them to live with pain if they cannot offer effective pharmacological options as part of an individualised approach. 

Alternative Guidance and Sources of Information

Chronic pain is a clinical area that is vast and ever evolving, particularly given the lack of understanding of chronic primary pain, so it is important to acknowledge that NG193—although anchored in current research—does have inherent limitations in its evidence base. When the guidance was published, critics noted that the GDG did not consider certain relevant Cochrane reviews in its evidence review,^5,7 and the guideline becomes more out of date as more new research is published. It is crucial that guidelines are kept up to date to mirror the latest medical insights; future guidance in this area could cover the genetic basis of pain perception or the potential of alternative therapies.

Healthcare professionals may be able to navigate the guideline’s limitations by staying up to date on emerging research, participating in educational workshops, and fostering collaborations across specialties. They may also benefit from being aware of, and using, alternative clinical guidelines. The Scottish Intercollegiate Guidelines Network’s 2019 guideline Management of chronic pain is the standard in Scotland, notably differing from NICE on the use of analgesia for the short- and medium-term management of pain, and is set to be updated in November 2024.^13,14 The All Wales Medicines Strategy Group also published a guideline on the pharmacological management of pain in November 2022,¹⁵ which recommends NSAIDs and antidepressants for chronic primary pain. Further, more specific, guidelines are also provided by the British Pain Society¹⁶ and the FPM of the RCA.¹⁷

Good Communication and the Provision of Information

Ultimately, clinicians can ensure that their care remains both evidence based and patient centred by maintaining open communication with patients and staying informed.¹ According to NG193’s evidence review, the experiences of patients with chronic pain interacting with healthcare professionals is a key development area in UK practice.^1,18 Hence, the guideline emphasises the importance of honest communication between clinicians and patients, which is so vital in an area like chronic pain in which the prognosis is uncertain and the limited treatment options may be poorly tolerated or ineffective.¹ Indeed, exploration of the patient’s ideas, concerns, preferences, and expectations about their condition is the foundation of any effective shared care and support plan.¹

Sources of information such as websites, patient information leaflets, self-help resources, and support groups can also be transformative for patients.^1,19 It is therefore important that patients are guided to credible sources of information and support.^1,19

Summary

Despite having some limitations, NG193’s emphasis on patient-centred, individualised assessment and management is almost universally accepted by chronic pain specialists and GPs alike. Open, effective communication—a key skill of primary care practitioners—is essential for managing patient expectations, and is the key to achieving better patient outcomes, even when clinicians are limited to a traditional 10-minute consultation.