NICE guidelines for chronic pain – a new approach
The National Institute for Health and Care Excellence (NICE) published new guidance on the assessment and management of chronic pain on 7 April 2021. The guidelines are primarily for patients with chronic pain with no underlying condition.
Chronic pain is defined as pain that has continued for a period in excess of three months, with the severity of the pain being irrelevant to the definition. The prognosis for suffers of chronic pain is generally variable and often poor. The guidelines recognise this uncertainty and the need for patients’ expectations to be measured.
Chronic pain claims are often expensive for insurers who may be faced with wide-ranging funding requests for treatment that has little prospect of success. The guidelines should be considered a welcome development and whilst they are not compulsory, and may not be suitable for all cases, insurers and their solicitors should advocate their application.
The guidelines recommend that medical practitioners conduct a patient centred approach to their assessment. This will include identifying psychological, biological and social factors contributing to their pain and analysing the impact on their lives. Practitioners are encouraged to understand the patient’s individual priorities, abilities and goals to create an individual care plan.
Some concern has been expressed that general practitioners will not have the capacity to undertake the detailed assessments envisaged and to review existing patients including their treatment plans. It will therefore be interesting to see how the guidelines are applied in practice.
The guidelines signal a move away from pharmacological options and expensive pain management programmes in favour of physical activity and psychological therapy. Practitioners are recommended to encourage patients to remain active and to offer supervised group exercise programmes to suit the patient’s ability and preferences or interests to increase the prospects of sustainability.
The availability of specialised pain exercise programmes may prove to be essential given that many chronic pain sufferers believe that their pain inhibits them from basic exercise and often activities of daily living.
The use of Acceptance and Commitment Therapy (ACT) or Cognitive Behavioural Therapy (CBT) is endorsed within the guidelines as being both cost effective and beneficial to patients.
The committee felt that consideration could be given to a single course of acupuncture, with studies showing that acupuncture provided short-term benefit to patients but there is insufficient evidence to determine any long-term benefits.
The committee found no evidence of any beneficial effect of the use of TNS, ultrasound and interferential therapy and confirmed that these treatments should not be offered.
The use of antidepressants is recommended, where appropriate, in a controlled manner, to assist with pain, sleep deprivation and psychological distress with or without a diagnosis of depression.
Conversely, the guidelines state that other pharmacological based methods for chronic pain including the use of ketamine, opioids, non-steroidal anti-inflammatory drugs and corticosteroid/local anaesthetic injections should not be used for new chronic pain patients and where possible, should be reduced for existing patients or ceased where no benefit is reported. The committee found no evidence that such medication made any difference and could potentially cause harm due to side effects or addiction.
The committee were also unable to recommend pain management programmes as patient studies did not demonstrate any significant benefit to enable them to determine the effectiveness of such programmes, both in terms in costs and benefit to the patient.
These guidelines are contrary to the usual practice adopted by many medico-legal experts and rehabilitation managers in chronic pain cases, where expensive pain management programmes and pharmacological solutions are regularly recommended.
The guidelines, including the absence of a positive endorsement of pain management programmes by NICE, may result in significant costs savings for insurers, which could be used to fund recommended treatment proven to have greater benefit. However, in a litigation setting, the absence of such treatment options may complicate recovery, by prolonging perceptions of pain, where the pain is psychologically mediated.