New draft NICE guidelines for chronic pain emphasises exercise, CBT and acupuncture over medication

I wonder how stressful GPs are going to find their consultations with patients talking about the need to drink heavily (to dull the senses), discussing starting on illegal drugs (for effective pain relief), threatening the use of self-harming coping mechanisms (an effective pain distraction) or committing suicide (the final solution) when using these shiny new NICE guidelines.
 
In some ways I am "fortunate" that the cause of my pain has become increasingly visible over the last 15 or so years. My structural spinal abnormality is now clearly visible, without Xrays.

I have therefore been pretty well supported by the local pain clinic for 21 years. They did offer some acupuncture in the early days, administered by their nurse specialist, but it was of no help to me. It soon stopped being offered on the NHS.
Fortunately, I have a tough gut and have been on Diclofenac for over 20 years and was able to access regular steroid injections to my sacro-iliac joints which helped.
I briefly tried gabapentin, prescribed by my GP, maybe 5 yrs ago, but it totally spaced me out.

I went back to the Pain Clinic, after this and was prescribed low dose opiate patches which have transformed my life. I am only on one patch per seven days, so can still drive except when pain levels are up due to too much standing or walking and I need top-up pain killers.
 
And the family of drugs that includes ibuprofen "made no difference to people's quality of life, pain or psychological distress".
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Madness.

Have these people never had a noticeable headache?

Did ibuprofen not make it go away or reduce it?

How can they say there is 'no evidence' when most people have this 'evidence' built into their very lives?

Slightly to the point - on what basis was ibuprofen given a license if it is so easily shown to do nothing?
 
Hutan said:
childhood trauma
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With childhood trauma being presented as a near universal cause or factor for almost all MUS, which according to BPS ideology makes up 1/4 to 1/2 of all medical complaints, you'd think people would also suggest that maybe something should be done about all that childhood trauma? Because it basically suggests that a very high % of people were basically physically and/or mentally tortured in their childhood.

Except that requires logic and so is not allowed, but seriously it's weird that so much blame is put on childhood trauma without anyone being bothered to pretend that it means something should be done about all those children being beat up by their parents. Maybe because it's a bit complicated to suggest that millions of people beat their children and have to actually defend and support it with data?

Edit: my bad, I said medical problems but actually they only view those as complaints
 
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Jonathan Edwards said:
Indeed. Pretending to be a doctor rather than pretending to be a patient.

I have not actually heard of 'Primary Pain' before. The next in a long line of weaselisms?
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Definitely a weasel word, it literally "means" unexplained. Because of course primary and unexplained mean the same thing. From NICE:
Chronic primary pain represents chronic pain as a condition in itself and which can't be accounted for by another diagnosis, or where it is not the symptom of an underlying condition (this is known as chronic secondary pain)
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This is as Orwellian as it gets. It's just using inoffensive common words to mean the same thing: conversion disorder. Always. That's frankly even more devious than "enhanced interrogation", which at least makes minimal semantic sense.
 
Some of the best or most interesting comments from medical staff printed in the comments on this link : http://www.pulsetoday.co.uk/news/gp...s-for-chronic-pain-says-nice/20041262.article

Please don't assume that I agree with all the comments I've selected to post.

someone most elegantly commented that we should have a block of wood for patients to put between their teeth when a similar suggestion to stop prescribing paracetamol for analgesia was mooted a few years ago.. perhaps we should be advising patients to enjoy the pain is pleasure principle now
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Daft. This is, in essence, ‘NICE recommends patients should just pull themselves together and suffer pain, despite there being lots of useful options for pain control’.
What’s next? ‘NICE recommends no pain control to be used in palliative care as they will be dead soon anyway’, perhaps?
Or maybe ‘NICE recommends withdrawal of all treatment, as it’s all ultimately futile and everyone dies at some point anyway’?
The danger here is that sensibly prescribing analgesia in primary care could now become ‘a performance issue’ in the eyes of NHSE.
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Sigh......
Genuinely not sure what I am supposed to do. A lot of chronic pain starts with acute pain. Persuading anyone in pain to stop appropriate analgesia and try alternatives without VAST resources is just setting up General Practice as useless and worth complaining about...
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Unfortunately if you go ‘off protocol’ you WILL be blamed* should the patient have and untoward outcomes.

*Including, but not confined to, CQC, GMC restriction of right to work, CCGs, civil prosecution +- unlimited liability if NHS indemnity doesn’t defend you, criminal prosecution +- loss of liberty, press vitriol +- loss of privacy, government criticism, physical and verbal assault unless the patient unless the patient made an initial warning within a narrow set of circumstances allowing immediate removal and some nasty Tweets.

I can handle staying off social media but the rest is tiresome.
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Contradictory incomprehensible ivory tower garbage
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Is NICE determined to relegate itself into being decommissioned?
The overall message here is bleak for patients, and impossible for GPs faced with the range of effects on patients' qol, sleep and ability to function.
One by one, tools to address the pain are deemed useless, while nebulous evidence for "acceptance therapy" somehow takes precedence.
Having seen the circuitous referrals back and forth to pain clinics and physio over decades,
the measures recommended here are unrealistic and of doubtful validity.
There is considerably more evidence for the effectiveness of manual therapy than there is for acupuncture or CBT/ACT.
NICE should never have approved gabapentinoids in the first place- they are useless.
Most patients are only too glad to ditch the opiates when their pain is eased. 30 years' practice tells me so.
I treat patients in general practice who've suffered (up to) decades of chronic pain. Using osteopathic manual therapy I have cured scores and relieved hundreds. Literally no-one in the medical MSK world is interested.
This is one of those guidelines that appears weak and unhelpful to both patients and doctors.
Inclusion of previously banned acupuncture smacks of desperation. There is nothing to recommend this guideline, or anything within it.
The lack of enquiry into addressing the causes of chronic pain is damning. RIP NICE.
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Thank goodness our Afghan brethren invested heavily in solar panels. No prescription will not mean no supply.
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So as a retired GP with arthritis issues who relies on an NSAID and occasionalparacetamol/co-codamol to effectively function, walk the dog, go to the gym in precovid days or even just get out of bed, etc I read this with horror and anger. I'm now 'just a patient' and I feel a sense of injustice and extreme frustration at this guidance. Some day those brilliant minds from NICE will be patients ......not too soon in my book !
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I agree with Good Dr.
Short term this will be a nightmare.
But long term, we can remove the codeine at 3 months, shrug, and say there’s nothing else to offer, unless they want an off license antidepressant. (And record that it is off license) The time-wasters/addicts will disappear (admittedly only after a fight), whilst the genuine will wait out the Pain Clinic referral.
The opiate boil must be lanced.
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I definitely don't agree with the above comment. I have a genuine need for pain killers, but if I'm turned away for any type of medical treatment I stay away because my experience of decades tells me that persisting just gets me shouted at, insulted, and possibly even thrown out of the surgery, or I end up talking to a doctor who behaves like a brick wall.

So despite numerous attempts by NHSE to completely destroy General practice while blaming it on the GPs, the GPs or what’s left of us, have kept the ship afloat and looked after our patients.
So now, the Ivory towers have turned to NICE and asked them to turn our patients against us.
If I’m in pain, i need a painkiller, not someone to talk to me after months, telling me I’m stupid to feel the pain
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'There was evidence that they could be "harmful" to patients and cause addiction NICE added'.

Hence: - 'After a full discussion of benefits and risks' Consider SSRIs et al.

So will both male and female, 16 year olds (upwards) be advised that these drugs (which are being used off label) may cause PSSD (post SSRI Sexual Dysfunction) which may be irreversible? That they may suffer great pain and distress from PGAD (Persistent Genital Arousal Disorder? That SSRIs have been used as a component of chemical castration "in selected, volunteer, sex offenders"?

That 1 in 5 may suffer clinically significant akathisia, with risk of misdiagnosis as 'bipolar disorder', or other life-labelling SMIs?

That these are psychotropic drugs which produce changes in feelings, emotions and behaviour: - vulnerable to mis-interpretation as depressive illness, and other M.H. diagnoses?
(Behavioural Toxicity --- danger to self/others)?

That for some, perhaps many, the withdrawal syndrome may be too intense to endure, and that withdrawal phenomena are also vulnerable to misdiagnosis as depression. That withdrawal may induce akathisia and self harm?

'We cannot be confident about which patients, if any, should receive antidepressants, but we can be confident that many people who are prescribed antidepressants should not be'.

Jureidini J. McHenry L. B. in The Illusion of Evidence-Based Medicine. 2020.
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Arnie Pye said:
I don't know her. Is she shopping-bag woman? Her grinning picture, in the context of this guideline, is enough to make me want to punch her repeatedly.
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Yes, and she is on the NICE committee for ME, despite having put in her submission that she was eager to promote a psychosocial framework, which should have disqualified her based on Edwards' BS disqualification for having a known public position. Not biased, though, obviously.
 
Radio 4 "covered" this today. The patient they chose to include was called something like "Emma Ellis" and runs a Pain Cafe in Torquay (sorry no idea what that it). The said that they had Fibromyaglia, degenerative disk disease, arthritis and chronic fatigue syndrome.

The gist of it was

She was in bed all day in agony, took lots of different drugs opiates and more

Went to talk to a pain clinic nurse, gentle exercise, did CBT, stopped the drugs

and is now well enough to work full time....

It here under World at one on R4 website. I can't bear to listen to it again. Starts around the 30 minute mark.

https://www.bbc.co.uk/sounds/play/m000lgj5

p.s. just found this

https://services.pinpointdevon.co.uk/kb5/devon/services/service.page?id=Rn8rLUMZJHM
 
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The danger involved in this sort of idealogical approach is clear from the BBC News coverage. Apparently 'chronic pain' of the sort to which the guidelines apply affects 30% of the population. The reality is that chronic pain due to easily identifiable causes affects 30% of the population and responds best to things like ibuprofen and paracetamol. Pain from no identifiable cause was in my experience as a rheumatologist pretty rare. That might of course be because it was always sent to my colleague who actively encouraged referrals of mysterious pain but most of my practice was unsorted referrals covering the full spectrum.
 
A bit tongue in cheek here but the next time you feel the need for an outburst of bile toward the medical establishment perhaps this could give some validation (straight from 'science'):

http://news.bbc.co.uk/2/hi/health/8147170.stm

A study by Keele University researchers found volunteers who cursed at will could endure pain nearly 50% longer than civil-tongued peers.
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Admittedly they were not referring to chronic pain here but just a matter of time one presumes.
 
Hutan said:
The arrogance is breath-taking at times. I can see that a little of what they propose might be useful for pain, but it goes horribly wrong when they try to apply it to ME/CFS or IBS.
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Re: PHARMAC seminar: Chronic pain, 5: Psychosocial and functional treatments
@23:18 Catastrophic thinking, Boom bust activity patterns - sounds like the crap Trudie Chalder says.
@30:21 Implying inconsequential symptoms, pain can't damage you, Software issue not hardware - I'm permanently bed bound thanks to doctors who hold those beliefs refusing to help me.
 
I know someone - extended family - who abuses prescription opiods and is probably the poster person for these guidelines. Their prescription drug stash includes fentanyl patches, liquid morphine & tramadol among others. This has been going on for years. The GP just keeps issuing the scripts.

The thing is I don't know anyone else or have read anything written by anyone on here who is quite like this person. She has a confirmed diagnosis of an extremely painful, debilitating condition that affects several members of my immediate family.

However, she refuses all the treatments that might affect, slow or possibly halt the disease process. Despite not being nearly as severely affected as some family members she is significantly more disabled because she insists on pain relief only.

Always a big person she is now massively overweight further limiting her.

I can't understand how her GP justifies this and dread to think what will happen when the day comes & they just cut off the supply because it's coming.

This is a very different situation from most people who suffer chronic pain but is probably being used as an excuse to deprive others of much needed treatment.
 
I've read the guideline a few times over now.

This is supposed to cover pain not explained by an existing condition. But it's not very clear from the guideline and one of the problems is how it will be applied.

E.g., if they think your pain isn't accounted for by the condition alone because it's too severe, then they can add the 'chronic primary pain' label to your diagnosis.

The guideline says, 'It should be used alongside NICE guidance for specific conditions that cause pain, including headaches, low back pain and sciatica,
rheumatoid arthritis, osteoarthritis, spondyloarthritis, endometriosis and irritable
bowel syndrome'.

This leaves a lot of scope for misuse, as 'alongside' could be taken to mean 'with' or 'at the same time' as those other guidelines.

The guideline then gives general advice, before detailing the treatment of 'chronic primary pain', which is poorly defined.

This will affect more women, as they say that chronic primary pain is associated with 'emotional distress'.

My guess is they will be made to clarify what it actually means and who this doesn't apply to, as it will otherwise be very unpopular. There are GPs with arthritis saying it sounds like it will affect them, for example, even though their pain is covered by another condition.

I think they were intending it to be used for fibromyalgia and similar conditions:

'The ICD-11 definition of chronic primary pain includes chronic widespread pain [i.e., fibromyalgia], complex regional pain syndrome, chronic primary headache or orofacial pain, chronic primary visceral pain and chronic primary musculoskeletal pain' (but this definition is tucked away near the end).

In most cases, this shouldn't cover pwME, unless you have comorbid FM. In such cases, it might be better to get your pain treated as neuropathic than 'chronic primary' if you can. Alternatively, if you can get your pain labelled as part of your ME, you may be able to make the case that it's secondary and not primary.
 
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