You can be certain of uncertainty and controversy with chronic pain

On the 3^rd of August this year, NICE released, for public consultation, draft clinical guidelines on the assessment and management of chronic pain in over 16s.

The accompanying headline was: “Commonly used treatments for chronic pain can do more harm than good and should not be used.” As you can imagine - this has caused a bit of a stir.

Painkillers: More harm than good?

The possibility that commonly used treatments for chronic pain could do more harm than good is something that has concerned me for decades. My concern has now been realised by an ‘Opioid Epidemic’ with widespread misuse of both prescription and non-prescription opioid pain killers. 

NICE recommends that common over the counter non-prescription drugs - including paracetamol and non-steroidal anti-inflammatory drugs - should not be offered for chronic primary pain:  “… 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 …”. 

NICE recommends that supervised group exercise programmes, some types of psychological therapy, or acupuncture should be offered instead. 

It will be interesting to see how practitioners and patients will react to these recommendations if they remain in the final guideline. 

You can be certain of uncertainty with acupuncture

NICE has been here before. In 2009, NICE published guidelines for the management of non-specific chronic low back pain with very similar recommendations, including acupuncture as first-line treatment.

The guidelines were met with derision and caused fractures within the British Pain Society.

Subsequently, the guidelines were updated with a complete U-turn on the recommendation for acupuncture: “Do not offer acupuncture for managing low back pain with or without sciatica.”

The period for consultation for the draft clinical guidelines on the assessment and management of chronic pain closed on 14 September 2020 and the final guidelines are due to be published in January 2021.

30 years of pain research at Leeds Beckett

The pain research team at Leeds Beckett waits in anticipation.

Research on the science of pain and its management at Leeds Beckett dates back to the early 1990s.

We have a broad portfolio of research including the epidemiology of pain (Dr Osama Tashani) and injury (Dr Gareth Jones), factors influencing response to pain (Dr Ghazala Tabasam) and mechanisms of pain perception (Prof. Mark Johnson).

At the core of our research have been projects into factors influencing the response to non-pharmacological treatments including acupuncture (Dr Carole Paley), transcutaneous electrical nerve stimulation (TENS, Prof. Mark Johnson), diet therapies (Ursula Philpott), kinesiology taping (Dr Gourav Banerjee), mirror therapy (Dr Priscilla Wittkopf), barefoot locomotion (Hannah Blackburn), and pain education for patients (Susan Hartup) and practitioners (Kate Thompson).

Our latest research findings

We recently published a synthesis of 177 reviews of acupuncture for chronic pain and concluded: “ … evidence that is conflicting and inconclusive, due in part to recurring methodological shortcomings of randomised controlled trials (RCTs).” NICE recommends acupuncture for chronic primary pain.

We have just completed the largest ever meta-analysis of research findings on TENS that included over 150 trials of chronic pain. NICE did not recommend TENS due to insufficient available data, they included only two trials. Our findings on TENS will be published in the near future.

An uncertain future?

We have argued that diet therapy chronic pain services would benefit substantially from access to dietitians skilled in the assessment, modification and support of diets specific to pain patients. NICE did not evaluate available research on diet therapy for chronic pain.

The role of NICE is to improve health and social care through evidence-based guidance.

Chronic pain is often described as a biopsychosocial phenomenon, although biomedical models of care using medication tend to dominate many areas of service delivery.

NICE should be commended for attempting to catalyse a shift away from wholesale reliance on medication. However, in doing so they are likely to create recommendations that will create uncertainty and controversy.