Statement of clarification on the latest NICE chronic pain guidance; regarding patients already on medication

The recent launch of Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain (NG193) is no different. The management of chronic pain has been included in the NICE Quality Standards topic library for many years. In a parallel development, the new ICD-11 definitions have allowed NICE to include the new concept of Chronic Primary Pain in the new guideline. As NICE states, ‘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’. The group includes many of the more complex pain conditions (e.g. fibromyalgia, Complex Regional Pain Syndrome) which can be challenging to manage for both the health care professional and especially for the patients concerned. In other words, changes to medical/drug management need to be handled carefully and with due diligence.

The guidance no longer recommends the initiation of many medications (e.g. NSAID’s, gabapentinoids, etc) for primary chronic pain. However, there are many patients in the community who are already using these medications. It is important that when implementing this guideline, that the recommendations are not used out of context.

Section 1.2.11 of the NICE guidelines clearly outlines the process that should be followed if a patient is already taking medication for chronic primary pain. The following points should be highlighted:

1. The new medication management principles are for Chronic Primary Pain and do not extend to other forms of Chronic Pain or Acute Pain (pain of less than 3 months' duration).
2. Section 1.2.11 of the new guidelines (when patients are already taking medication for Chronic Primary Pain) should be viewed as an ideal opportunity within routine consultations to review continued medication usage. If the patient declares benefit from the medication then a shared plan can be developed using shared decision-making processes, explaining any risks and the lack of evidence. If the patient has no benefit from the medication, then using the same process, a staged reduction plan can be formulated. In all cases, additional or alternative methods of managing pain (as outlined in the guidance) can be explored.

Many of these reviews will take place in Primary Care, and there is extreme pressure on GPs and teams at present. However, when patients do present for review, we hope this information helps give a structure to the consultation.

Further information

The RCGP One Day Essential Pain Conference on Friday 23 April 2021 will cover this in greater detail and will be available for viewing after the event on the RCGP eLearning portal.

British Pain Society are holding a webinar on the NICE chronic pain guidelines at 6:30pm on Thursday 22 April 2021. Recordings of the event will be on the BPS website.

Notes to editor

The Royal College of General Practitioners is a network of more than 52,000 family doctors working to improve care for patients. We work to encourage and maintain the highest standards of general medical practice and act as the voice of GPs on education, training, research and clinical standards.