Managing chronic pain is complex but analgesics are not the first line treatment option, as Victoria Goldman explains…

Chronic pain affects between one third to one half of the UK population, according to the April 2021 NICE guideline¹ on the assessment and management of chronic pain.

Chronic pain is defined as continuous, long-term pain of more than 12 weeks. It may be secondary to a medical condition such as low back pain, arthritis, ulcerative colitis, migraine or endometriosis, or it may be primary with no clear underlying cause, such as in fibromyalgia. The prevalence of chronic primary pain is unknown but is estimated to be between 1-6 per cent in England.

Although the number of people seeking advice for chronic pain has risen with the ageing population, chronic pain doesn’t only affect older people. Research funded by the Health Foundation and published in the journal Plos One in November 2022² showed that more than two-fifths of people in Britain suffer from some form of chronic pain by the time they reach their mid-40s.

“Chronic pain is a serious problem affecting a large number of people,” says study co-author Professor Alex Bryson, of University College London’s Social Research Institute. “Tracking a birth cohort across their life course, we find chronic pain is highly persistent and is associated with poor mental health outcomes later in life including depression, as well as leading to poorer general health and joblessness.”

Management approach

Chronic pain management is complex. For chronic primary pain, according to the NICE guideline, healthcare professionals should recommend exercise programmes, psychological therapies such as CBT, and acceptance and commitment therapy (ACT), and acupuncture, rather than analgesics.

Patients can be referred by their GP to a pain clinic and then enrolled onto a pain management programme, although these aren’t available in all areas. The NICE guideline places emphasis on shared decision making, and suggests that an individualised care and support plan should be developed, based on the effects of pain on day-to-day activities, as well as the patient’s preferences, abilities and goals.

“Pain can cause untold misery for patients and their families,” wrote Professor Martin Marshall, chair of the Royal College of GPs, when the NICE guideline was published in April 2021.

“GPs will always take a holistic approach to delivering care, considering physical, psychological and social factors when making a diagnosis and developing a treatment plan in partnership with our patients. We also understand the move away from a pharmacological option to treating chronic primary pain to a focus on physical and psychological therapies that we know can benefit people in pain. However, access to these therapies can be patchy at a community level across the country, so this needs to be addressed urgently.”

Exercise benefits

According to the NICE guideline, people with chronic primary pain should be offered a supervised group exercise programme. Exercise can help to ease pain directly by blocking pain signals to the brain, while stretching can improve the flexibility of muscles, ligaments and joints.

Patients should pick a form of exercise that they enjoy and which doesn’t put them under too much strain, such as walking, swimming, using an exercise bike, dancing, yoga or pilates. According to the NHS website,³activity and stretching should be an important part of daily life in chronic pain management. Gentle exercise may seem painful at first but is unlikely to cause any damage or harm.

Physical therapies

A GP may be able to refer a patient for physical therapies on the NHS in some areas of the UK, but these therapies often need to be accessed privately. Physical therapies help people to move more easily and can help to make daily tasks easier. These are usually delivered by a physiotherapist, chiropractor or osteopath.

Patients are encouraged to exercise within manageable levels of pain, gradually increasing activities or carrying out ‘phased activities’ and/or pacing.⁴ With pacing, patients learn to briefly stop before their pain or other symptoms, such as numbness or pins and needles, increases.

For chronic primary pain, the NICE guideline also suggests a single course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system. “Evidence has shown that acupuncture actively improves rates of healing and recovery, thereby enhancing treatment outcomes,” says Paul Battersby, chief executive officer and clinical advisor at the Acupuncture Association of Chartered Physiotherapists (AACP).

“Pharmacists can refer customers to a practitioner through the Acupuncture Association of Chartered Physiotherapists (AACP) online practitioner search tool.”

Psychological support

Chronic pain can be difficult to deal with emotionally, causing mood changes, anxiety and depression. The NHS website recommends deep breathing exercises to encourage relaxation and stop muscle tension from making existing pain worse.

Many people with long-term pain find it difficult to sleep at night, so sleep hygiene practices are important as well.

Some people with chronic pain find it helpful to see a counsellor, psychologist or hypnotherapist. Research published in the British Medical Journal in March 2022⁵ found that psychological therapies for chronic non-specific low back pain are most effective when used with physiotherapy (mainly structured exercise).

Painkillers

For chronic primary pain, NICE recommends that patients shouldn’t be started on commonly used medicines such as paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), benzodiazepines or opioids, as there’s little or no evidence that these medicines make a difference to patients’ quality of life.

However, the NHS website suggests that taking over-the-counter painkillers, such as paracetamol or ibuprofen, may be useful in reducing chronic pain so that patients can become more active. Some adults may benefit from taking an antidepressant to help with quality of life, pain, sleep and psychological distress, even without a diagnosis of depression.

Signposting

Self-management approaches are important in chronic pain relief. A GP may be able to refer patients to the Pathway through Pain digital online course (www.pathwaythroughpain.com). Pharmacy customers may also benefit from information and support from the following websites:

• British Pain Society (www.britishpainsociety.org)
• The Pain Toolkit (www.paintoolkit.org)
• Pain Concern (https://painconcern.org.uk)
• Action on Pain (www.action-on-pain.co.uk)
• Versus Arthritis (www.versusarthritis.org)
• BackCare (https://backcare.org.uk)
• Live Well with Pain (https://livewellwithpain.co.uk)
• Flippin’ Pain (www.flippinpain.co.uk)

References