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Painkillers ‘should not be prescribed for chronic pain’

Painkillers such as paracetamol and ibuprofen can do ‘more harm than good’ and should not be prescribed to treat chronic pain, health officials have said.

The National Institute for Health and Care Excellence claims that there is ‘little or no evidence’ the drugs, as well as aspirin and opioids, work.  

But in draft guidance, published on Monday, Nice said there was evidence painkillers can cause harm, including addiction.

It says it would be ‘inappropriate’ for them to offered to patients anymore, despite the NHS saying paracetamol is safe when taken over many years.

Nice suggests people with chronic pain are instead offered exercise classes, therapy, acupuncture or even antidepressants. 

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.

Doctors often define chronic pain as any pain that lasts for three to six months or more.  

It is notoriously difficult to treat, and is characterised by significant emotional distress and functional disability.

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The draft guidance, which is open to public consultation until August 14, said that paracetamol, non-steroidal anti-inflammatory drugs (NSAIDS) such as aspirin and ibuprofen, benzodiazepines or opioids should not be offered to people with chronic pain. 

There is little or no evidence that they made any difference to people’s quality of life, pain or psychological distress, the guidance said, and in some cases are harmful.

Studies have suggested that patients who took benzodiazepines and NSAIDS had poorer psychological and physical functioning. 

The guidance did not give details about how paracetamol is harmful. However, it is known that overdosing on paracetamol can cause serious side effects. 

Antiepileptic drugs including gabapentinoids, local anaesthetics, ketamine, corticosteroids and antipsychotics should not be prescribed to people to manage chronic primary pain because, again, Nice said there is little or no evidence that these treatments work but could have possible harms. 

The guidance said: ‘The committee agreed that not commenting on these medicines could result in their continued use in practice, which would be inappropriate given the lack of evidence and possible harms, so they recommended against the use of these treatments.’ 

Currently the NHS website says it’s safe for people with chronic pain to use over-the-counter painkillers to avoid becoming inactive from the condition.

It warns they must be taken appropriately, but says: ‘It’s safe to take paracetamol regularly for many years as long as you don’t take more than the recommended dosage.’

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 said: ‘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.’

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.’

The committee said that people with chronic pain should be offered group exercise programmes, some types of psychological therapy, or acupuncture.

Evidence from 23 studies has shown exercise can reduce pain, while 22 showed it improved quality of life. 

But it is known that it can be a difficult feat for someone with pain to get up and exercise. 

Evidence suggests cognitive behavioural therapy (CBT), which is already used in the NHS for chronic primary pain, improves quality of life and is not harmful.

A newer type of therapy called ‘acceptance and commitment therapy’ has been shown in a small number of studies to improve quality of life and sleep, and reduce pain and psychological distress.

The committee agreed that there was a large evidence base showing acupuncture – when fine needles are inserted at certain sites in the body – to be clinically effective in the short term, up to three months, but the evidence is weaker for long term benefits. 

It also recommends that some antidepressants can be considered for people with chronic primary pain. 

But the committee noted the risks of withdrawal symptoms – such as anxiety, dizziness and insomnia – should be considered, however, and the drugs should not be continued if they were not effective.  

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