Common painkillers for chronic discomfort could ‘do more harm than good’, says Nice
Chronic-pain patients should not turn to analgesics to ease their discomfort, an official health body has said.
The National Institute for Health and Care Excellence (Nice), which offers guidance for the NHS, has stressed commonly-prescribed painkillers like paracetamol, aspirin and opioids “have little or no evidence they work”.
The treatments could even do “more harm than good” if a patient develops an addiction, it warned.
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Nearly six million people in England and Wales were prescribed opioids in 2019, twice as many as 20 years ago. While the UK situation is considerably less severe than the addiction epidemic in the US, overdose deaths are on the rise.
Nice urges patients should instead be prescribed exercise, psychological therapy or acupuncture.
‘Little to no evidence’ common painkillers ease discomfort
Chronic pain, whether a recurrent headache or back discomfort, affected between 13% and 50% of Britons in 2019.
While pain is a spectrum, 10.4% to 14.3% suffered moderately or severely.
The NHS recommends a combination of exercise, physical therapy and painkillers to ease the debilitating symptom.
Over-the-counter analgesics include paracetamol or the anti-inflammatory drug ibuprofen.
In more severe cases, amitriptyline or gabapentin may be prescribed for pain caused by nerve sensitivity or damage, like shingles or sciatica.
The strongest painkillers available are morphine or similar-acting drugs, like opioids.
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In its new report Chronic pain: assessment and management, Nice warns “a number of commonly-used drug treatments for chronic primary pain have little or no evidence they work and shouldn’t be prescribed”.
Chronic primary pain is a condition in itself, rather than that which occurs as a symptom of another diagnosis.
The report states antidepressants may relieve discomfort in some cases.
It adds paracetamol, non-steroidal anti-inflammatory drugs – like aspirin and ibuprofen, benzodiazepines – “benzos”, and opioids should not be offered, however.
“This is because, while 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,” wrote the team behind the report.
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Opioids are most often associated with addiction, with many abusers experiencing euphoria, followed by withdrawal symptoms.
Misuse can lead to life-threatening respiratory depression, when the lungs fail to exchange carbon dioxide and oxygen efficiently.
An increasing number of fatalities in the UK mention an opioid pain medicine on the death certificate. The drug tramadol is specifically behind around 240 deaths a year.
In the US, more than 67,000 people died from a drug overdose in 2018, of which almost 70% involved a prescription or illicit opioid.
Unlike in the US, the UK’s publicly-funded healthcare system means patients cannot go from doctor to doctor requesting treatment, experts said at a Science Media Centre briefing in January.
Britons also have access to opioid substitution therapy, they added.
Patients prescribed ‘ineffective but harmful drugs’
Opioids aside, Nice stressed chronic-pain patients should also not be offered local anaesthetics, ketamine, corticosteroids or antipsychotics.
“Again, this was because there was little or no evidence that these treatments work but could have possible harms,” wrote the team.
They recommend acupuncture for some patients, “provided it is delivered within certain, clearly defined parameters”.
Inserting needles into problem areas is said to stimulate sensory nerves under the skin and in the muscles, triggering the release of pain-relieving endorphins.
Nice recommends acupuncture for chronic tension-type headaches or migraines. There is also evidence it may ease joint, dental or post-operative pain.
Acupuncture is sometimes available on the NHS, however, most have it privately.
Nice’s report – which is in a draft stage – also stresses patients should be at the centre of their care, with a supportive relationship being fostered between the individual and the healthcare professional.
“What this draft guideline highlights is the fundamental importance of good communication to the experience of care for people with chronic pain,” said Paul Chrisp from Nice.
“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.”
Dr Nick Kosky – a consultant psychiatrist at Dorset HealthCare NHS University Foundation Trust and chair of Nice’s guideline committee – added a “mismatch between expectations and treatment outcomes” can affect the relationship between a healthcare professional and the patient.
As a “consequence”, patients may be prescribed “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 patient’s expectations,” added Dr Kosky.
