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Suggested Learning

When the drugs won’t work

Analgesics can provide relief from pain but there are times when people aren’t able to take them, or just don’t want to, writes Steve Titmarsh
 


In cases of chronic pain, patients may not want to take any medication to avoid long-term regular use of drugs. In such a situation non-pharmacological approaches to pain management might be just what the doctor needs to order - or the pharmacist for that matter.
It is thought that chronic pain might affect 1 in 3 to 1 in 2 of the UK population, but the proportion of those people who need or want treatment is unknown.1

When developing a care and support plan for people with chronic pain it is important to discuss their priorities, abilities and goals, and find out what they are already doing that is helpful.1 You should also find out about their preferred approach to treatment, and balance of treatments for multiple conditions.

For young adults (aged 16 to 25 years) inquire about the support they need to enable them to continue with their education or training, if appropriate.

Non-pharmacological approaches to chronic pain management fall into two broad categories – physical (or sensory) and psychological interventions2 – and include:3

·       Acupuncture
·       Massage therapy
·       Physical therapy, such as exercise
·       Cognitive behavioural therapy
·       Transcutaneous electrical nerve stimulation (TENS)
·       Relaxation, including aromatherapy, deep breathing, meditation and yoga
·       Biofeedback
·       Self-hypnosis.

In guidance published in April 2021 the National Institute for Health and Care Excellence (NICE) recommends non-pharmacological approaches such as supervised exercise, psychological therapies and acupuncture for the management of chronic primary pain. This is defined as pain lasting more than three months, but excluding neuropathic pain, low back pain and osteoarthritis in people over 16 years old.1

Chronic primary pain has no obvious cause, or seems to be out of proportion to any apparent injury or disease. Examples include fibromyalgia (chronic widespread pain), complex regional pain syndrome, chronic primary headache and orofacial pain, chronic primary visceral pain, and chronic primary musculoskeletal pain.

NICE adds that a number of factors need to be taken into account when assessing chronic pain as they always influence how pain is experienced by an individual.1 These include:

·       social factors, including deprivation, isolation, lack of access to services
·       emotional factors, including anxiety, distress, previous trauma
·       expectations and beliefs
·       mental health, including depression and post-traumatic stress disorder
·       biological factors.

NICE says it is important to acknowledge that treatment may be ineffective or not well tolerated by some people. It is important to be honest about what to expect from treatment and to be clear what the priorities are for each individual patient. A person’s priorities, preferences, abilities and goals will help inform a treatment plan.1

Evidence of efficacy
Exercise, both in the long and short term, was found to reduce pain (23 studies) and improve quality of life (22 studies) when compared with the usual care given to people with chronic acute pain.1 Although evidence comes from a relatively small number of studies, acceptance and commitment therapy (ACT) was found to improve quality of life and sleep and reduce pain and psychological stress.1

ACT does not seek to relieve symptoms – rather it equips people with pain to adopt behaviours that change the way they experience their feelings and sensations, to divert them from struggling with their pain and to engage with their values and ways they can achieve their goals. So it encourages people to accept their symptoms and focus on what their values and goals are.4,5

Cognitive behavioural therapy (CBT) has been shown to improve quality of life for people with chronic primary pain.1CBT focuses on reducing pain and distress by modifying physical sensations, catastrophic thinking, and maladaptive behaviors.6
NICE recommends that ACT and CBT should be considered for chronic primary pain in people aged 16 years and older and delivered by a trained healthcare professional.1

However, NICE found evidence for biofeedback for chronic primary pain conflicting, and there was not enough evidence to recommend relaxation therapy, mindfulness or psychotherapy. Nevertheless, NICE comments that with further research that may change.1

Acupuncture has been shown to reduce pain and improve quality of life in 27 studies identified by NICE comparing the intervention with a sham procedure. The evidence base supports acupuncture being effective over three months. Whether the effect is sustained long term is unclear.1
NICE recommends considering one course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system, for people aged 16 years or over for chronic primary pain. The intervention should be delivered by a trained healthcare professional.1

Laser therapy and transcranial magnetic stimulation were the only electrical therapies that showed any benefit in patient-reported pain. Some improvement in quality of life was evident with laser therapy. However, NICE could not find sufficient evidence of sufficiently high quality to make specific recommendations for the use of these modalities, noting instead that because the limited evidence was promising further research was needed.1

TENS does not have evidence to support its effectiveness. Similarly, there does not seem to be any evidence to show the efficacy of ultrasound or interferential therapy. There is limited evidence for the efficacy of peripheral electrical nerve stimulation (PENS) or transcranial direct current stimulation.1

Some non-pharmacological interventions can also be effective in acute pain (that is pain lasting less than three months or sometimes longer if there is an obvious cause).

For example, acupuncture has been found to be effective in reducing pain after surgery compared with usual care. Patients also needed fewer opioids to reduce pain symptoms. The procedure has also been shown to be effective for subacute low back pain and acute migraine.

In one trial of almost 2,000 people acupuncture had a similar effect to drug treatment in patients with acute low back pain and ankle sprain presenting to accident and emergency departments.7 However, NICE does not recommend acupuncture for low back pain, recommending a group exercise programme instead.8

Massage therapy produces a significant effect on postoperative pain. Virtual reality as a distraction technique in combination with drug therapy, and music therapy reduce pain in burn patients.7
 

Further information
• PainSupport – https://painsupport.co.uk/pain-relief
• Action on Pain – www.action-on-pain.co.uk
• British Pain Society – www.britishpainsociety.org/mediacentre/news/joint-statement-of-clarification-on-the-latest-nice-chronic-pain-guidance-regarding-patients-already-on-medication
• Pain concern – https://painconcern.org.uk/self-management
 

References

1. National Institute for Health and Care Excellence (NICE). Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE guideline (NG193) (www.nice.org.uk/guidance/NG193; accessed September 2021).
2. El Geziry A, Toble Y, Al Kadhi F, et al. Non-pharmacological pain management. In: Sallik NA. Ed. Pain management in special circumstances. London: IntechOpen, 2018
3. Drugs.com. Non-Pharmacological Pain Management Therapies for Adults (www.drugs.com/cg/non-pharmacological-pain-management-therapies-for-adults.html; accessed September 2021).
4. McCracken L. ACT for chronic pain (www.div12.org/wp-content/uploads/2015/06/ACT-for-Chronic-Pain-manual-McCracken.pdf; accessed September 2021).
5. Black R. CBT and ACT Therapy for Chronic Pain: How Does Psychotherapy Help? (www.practicalpainmanagement.com/patient/treatments/mental-and-emotional-therapy/cbt-act-therapy-chronic-pain-how-does-psychotherapy; accessed September 2021).
6. Lim JA, Choi SH, Lee WJ, et el. Cognitive-behavioral therapy for patients with chronic pain: Implications of gender differences in empathy. Medicine 2018;97(23):e10867.
7. Tick H, Nielsen A, Pelletier KR, et al. Evidence-based nonpharmacologic strategies for comprehensive pain care: the consortium pain task force white paper. Explore 2018;14:177–211.
8. Low back pain and sciatica in over 16s: assessment and management
NICE guideline (NG59) (https://www.nice.org.uk/guidance/NG59/chapter/Recommendations#non-invasive-treatments-for-low-back-pain-and-sciatica; accessed September 2021).
 
 
 
 
 




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