NICE recommends that antidepressants – duloxetine, fluoxetine, paroxetine, citalopram, sertraline or amitriptyline –be considered for chronic primary pain despite this not being within their licensed indications.2

Available evidence indicates that antidepressants improve quality of life, pain and psychological distress compared with placebo in chronic primary pain, said NICE. “But there were some limitations in the quality and amount of the evidence.” Most of the evidence NICE has relied upon comes from women with fibromyalgia.

“However, the committee agreed that for most medicines, response to treatment would be sufficiently similar to allow recommendations to be made across all chronic primary pain conditions, even when evidence was available for only one condition.”

Medicines which NICE says should not be offered for chronic primary pain are:

·       opioids

·       non-steroidal anti-inflammatory drugs (NSAIDs)

·       paracetamol

·       benzodiazepines

·       anti-epileptic drugs including gabapentinoids

·       local anaesthetics

·       local anaesthetic/corticosteroid combinations

·       ketamine

·       corticosteroids

·       antipsychotics.

Patients with chronic primary pain need to be aware of the risks of continuing treatment with any of these medications. They should also be aware of potential withdrawal problems if they decide to stop taking a medicine.