Justifying the off-label usage of antidepressants for chronic primary pain, NICE said: “… there are no licensed alternatives for this indication and these medications are already used in practice”. However, it found limited or no evidence for many of the medicines currently used for chronic primary pain.2

What evidence there was for NSAIDS suggested that being used short-term use made no difference to the pain, quality of life, or psychological distress. NSAIDs may even reduce physical function, compared with placebo. Side-effects such as gastrointestinal bleeding and the lack of evidence of short or long-term effectiveness meant NICE could not recommend NSAIDs for chronic primary pain.

There was no evidence either for the effectiveness of opioids, but some non-randomised studies indicated an increased risk of dependence. NICE also found no evidence for the use of paracetamol, corticosteroids, or combination anaesthetic/corticosteroids.

“The committee agreed that not commenting on these medicines could result in their continued use in practice, which would be inappropriate given the lack of evidence and possible harms, so they recommended against the use of these treatments.”

NICE Guideline NG144 ‘Cannabis-based medicinal products’, (November 2019) already advises that cannabinoids should not be offered for chronic pain, unless part of a clinical trial.21