Pain management – cat among the pigeons

October 5, 2020
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“Life is pain…anyone who tells you differently is selling something”

William Goldman, The Princess Bride

Pain and addiction are intertwined. Prescribed medication for pain can be a route into addiction. In practice I regularly see people on multiple medications for pain, making treatment of their addiction challenging.

Last year Public Health England found that one in four people were taking ‘addictive’ prescription medicines. It looks like this is eclipsed by the situation in the US with a 2016 SAMHSA report stating ‘an estimated 119.0 million Americans aged 12 or older used prescription psychotherapeutic drugs in the past year, representing 44.5 percent of the population’. A third of this was pain medication.

This suggests there’s a lot of pain around. But pain needs to be addressed appropriately so it’s no surprise that there’s a lot of analgesic prescribing. It’s needed – right?

Well not so fast. The evidence for the benefit of opioids, for example, in chronic pain is pretty dire. Where studies have been done, the follow-up period is generally ultra-short.

So how confident can we actually be that opioids are both effective and safe in chronic pain? Well we can look to the highest standard of evidence, randomised controlled trials (RCTs).

See this flow chart for an analysis of the evidence base to 2012. It’s not particularly impressive to put it mildly. Yet millions of people have ended up on long-term opioid pain medication.

Now the UK National Institute for Health and Care guidance (NICE) has issued draft guidelines for the management of chronic pain. NICE aim to improve outcomes by setting out evidence-based guidelines. What do they say? Well, it’s pretty clear, not to mention stark:

Do not offer any of the following, by any route, to people aged 16 years and over to manage chronic primary pain: 

  • opioids
  • non-steroidal anti-inflammatory drugs
  • benzodiazepines
  • anti-epileptic drugs including gabapentinoids, unless gabapentinoids are offered as part of a clinical trial for complex regional pain syndrome
  • local anaesthetics, by any route, unless as part of a clinical trial for complex regional pain syndrome
  • local anaesthetic/corticosteroid combinations
  • paracetamol
  • ketamine
  • corticosteroids
  • antipsychotics 

This is a pretty revolutionary development and has set the cat somewhat amongst the pigeons. It’s still in draft, so may be modified, but by any measure it’s quite a change.

Reporting on the response to this of the Faculty of Pain Medicine of the Royal College of Anaesthetists who had concerns about category definitions of pain, the Pharmaceutical Journal said that the terminology was “highly confusing and damaging” and that there was a “serious risk” that the recommendations would be taken to apply to all chronic pain. It said that this “essentially” resulted in the guidance “not being fit for purpose”.

GPs have also expressed concerns around limited options with Pulse magazine reporting: ‘NICE has also missed the glaringly obvious contributing factor of social deprivation… chronic pain is almost overwhelmingly a problem of deprivation and despair.’

Given the number of people who present in primary care with chronic pain, I can understand those concerns. Although antidepressants are recommended in the guidance, alternative approaches to prescriptions take time and expertise to deliver. But what does this mean for all those people already on long term medication?

I am left wondering how we ended up with so many people on medication for pain with so little evidence of efficacy. My thoughts turn to Big Pharma and a commentary by Des Spence I read a few years ago in the British Medical Journal (restricted access):

Research always reports underdiagnosis and undertreatment, never the opposite. Control all data and make the study duration short. Use the media, plant news stories, and bankroll patient support groups. Pay your specialists large advisory fees. Lobby government. Get your pharma sponsored specialists to advise the government. So now the world view is dominated by a tiny group of specialists with vested interests. Use celebrity endorsements to sprinkle on the marketing magic of emotion. Expand the market by promoting online questionnaires that loosen the diagnostic criteria further. Make the illegitimate legitimate”

Is he right?

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