GPs, nurses and practice pharmacists need to work together to manage patients’ expectations in regards to managing their chronic pain.
Chronic pain places a huge burden on millions of patients, families and carers in Great Britain. However, despite being such a prevalent condition, the tools for managing it are unfortunately blunt.
Pharmacological options — such as opioid analgesics — have traditionally been the first port of call in this area, but there are well-known problems with this treatment option. Although a small percentage of patients may find opioids effective for chronic pain, a 2019 review by Public Health England has concluded that, for most people with chronic non-cancer pain, opioids do not provide adequate clinical benefit when balanced against the risks of dependence and overdose poisoning, and harms to others in the community.
There are similar problems with other classes of drugs. Gabapentinoids are recommended by the National Institute for Health and Care Excellence (NICE) for neuropathic pain, but there are concerns over their misuse.
NICE also recommends the antidepressants amitriptyline and duloxetine for neuropathic pain, although amitriptyline is associated with several adverse effects and is dangerous in overdose. Duloxetine has greater relative safety in overdose and more tolerable side effects, but, nevertheless, around one in six people discontinue it because of its side effects.
Seasoned pharmacists will remember the Vioxx scandal in the early 2000s, which highlighted the side effects associated with cyclooxygenase-2 inhibitors, leading to a re-evaluation of the whole non-steroidal anti-inflammatory drug (NSAID) class. NICE now says that NSAIDs can be considered for low-back pain, but risk factors for gastrointestinal, liver and cardio-renal toxicity should be taken into account.
Many experts say that the current model for the treatment of chronic pain is broken. The use of stronger analgesics to treat chronic pain gained popularity in the 1990s following inappropriate adoption of the World Health Organization’s analgesic ladder, which was originally developed amid heavy marketing from pharmaceutical companies for cancer-related pain.
Now we are in a situation where patients often expect to be prescribed medicines that will treat their chronic pain, assuming that because they work for acute pain, they will experience a similar effect for more persistent pain. However, this perception inevitably leads to disappointment.
GPs now have few options to prescribe and limited time to spend with patients to adjust their expectations. As shown in our investigation this month, specialist pain management services have adapted to offer more holistic care for patients, with psychological interventions, exercise programmes and physiotherapy. But long waits — for years or more in some cases — mean that patients can deteriorate significantly before receiving the help they need.
Perhaps with the advent of primary care networks in England, this will finally be tackled. Moving to a model where more patients with chronic pain can access non-drug alternatives and counselling quickly should help lead to better success rates. Linking in community pharmacy with this effort is crucial too, since many patients with chronic pain will be buying over-the-counter analgesics.
However, perhaps the major change needed first is a campaign to manage patients’ expectations about drug treatment for chronic pain, explaining that rehabilitation is not a denial of pain but a way of living with it. That will require more resources in order to ensure that GPs, nurses or practice pharmacists can spend the time needed with patients.
A draft version of the new NICE guideline for the assessment and management of chronic pain is due to be published on 21 February 2020, and we hope that this will point towards a new way of managing chronic pain. It is desperately needed.