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

Jonathan Edwards said:
Very very much so.
It is intriguing that paired test treatments always seem to come out exactly the same.
If you try two unvalidated treatments what would be the chances that they would actually be more or less identical in efficacy - close to zero. Yet for PACE and here the test groups show the same effect in comparison to 'usual dross treatment'. It does look suspiciously like a consistent bias effect.
Perhaps the surprising thing is that mindfulness and CBT therapists seem to have exactly the same placebo potential. I would have thought the different coloured cardigans might skew that.
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Perhaps you have to be colour blind to participate?

ETA or perhaps they swop cardigans halfway through....
 
This article was published when the new chronic pain guidelines were in draft form (Sep 2020), and I think it is worth reading :

Title : ‘Hysterical until proven otherwise’: how NICE is trying to tell women their pain is all in their heads

Link : https://hystericalwomen.co.uk/2020/...wise-nice-tell-women-pain-all-in-their-heads/

I have a question on this new guidance. If people are always assumed to have chronic pain with no cause when they first turn up in a doctor's surgery how are mistakes in diagnosis ever rectified? It seems to me that the answer is never, and life-long torture is going to become the gold standard for pain treatment.
 
Women with chronic pain are already dismissed – new guidelines denying them painkillers are a disaster
New guidance from health officials on the treatment of chronic pain could be devastating for women already struggling to get doctors to take their pain seriously.

The guidelines, published on Wednesday by the National Institute for Health and Care Excellence (NICE), say that patients suffering from chronic pain that has no known underlying cause (known as chronic primary pain) should not be prescribed painkillers. Instead, it suggests, these patients should be offered exercise, antidepressants, talking therapies and acupuncture.

This has huge implications for the future treatment of anyone living with unexplained chronic pain – the majority of whom are women – and runs the risk of patients being viewed as hysterical until proven otherwise.
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Speaking to me this morning, Ellie describes the final guidance as “completely inappropriate and completely devastating” for the mostly female chronic pain community she works with. “It’s just awful. We hope NICE listens to feedback and this goes the way of graded exercise therapy (GET),” she says. GET uses gradual increases in exercise to treat patients with the chronic illness myalgic encephalomyelitis (ME). GET which was recently removed from the latest draft of NICE guidance in response to patient reports that it was not only ineffective but, in many cases, actively harmful. A draft of the updated NICE guidance states that GET “should not be offered as a treatment for ME/CFS”.
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https://inews.co.uk/opinion/women-chronic-pain-new-guidelines-deny-painkillers-945582
 
The lack of evidence for pharmacological treatments in chronic primary pain, other than for anti-depressants, seems to be a direct consequence of the psychiatric/biopsychosocial approach to its clinical management and to research on it. Comparing the numbers of studies that were included for each type of treatment highlights this issue (section 1.4.1):

- Exercise: 91 studies and 3 Cochrane reviews with 32 comparisons of interventions

- Psychotherapy: 47 studies with 18 comparisons

- Pharmacological management: 34 studies with 11 comparisons, including 22 studies on anti-depressants vs. 5 for NSAIDs, 5 for benzodiazepines, none for opioids

The evidence base was such that the NICE committee got to consider 4 times as many studies on exercise and psychotherapy combined than pharmacological management, and twice as many on anti-depressants than other drugs. A question that comes to mind, then, is that while pharmaceutical laboratories might be content from a financial viewpoint with the recommendation of anti-depressants, would it not also be interesting for them to generate evidence on painkillers for the treatment of chronic primary pain?

Another issue with the evidence base is how trials of painkillers were designed. Their trials were of continuous usage, but this is not sensible nor realistic due to their adverse effects. I reckon that most patients are aware of the risk of harm and many (but not all) try to reserve their usage of painkillers to the most difficult times of a pain flare -- taking them spontaneously, not continually, throughout the course of a few hours to a few weeks --. I would think that, had patients with chronic primary pain been properly involved in research/designing trials, by now we would have trials of spontaneous usage.

Also, therapeutic education on painkillers has an important role to play on their responsible usage, but how consistently is it provided to people with chronic primary pain -- who are often dismissed by MDs --? I am not sure that the NICE guideline proposed this as a harm reduction method (but the old one might have). I do not know the literature on chronic secondary pain (with an identified cause) but I suppose the above points must have been studied in this context. In the evidence review, there is no sign that they were discussed.
 
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Jonathan Edwards said:
Is anyone familiar wit the trial literature for chronic pain? What is the pain equivalent of PACE I wonder?
Pain would seem to pose an even bigger methodological problem since it is subjective all the way.
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I haven't had a close look recently but from recall a lot is of similar design to PACE/FINE. E. G. pretty much all uses subjective outcome measures and questionnaires in trials that are hard to blind on complex multicomponent programmes like PMPs etc. However, these are categorically not aimed at cure or pain reduction. That is big difference to PACE or MUS type approach that aims to cure when even the eb for helping people to cope is of low quality.

The British Pain Society guidelines for PMPs will have references relating to that.
 
Same here in this article from Science based medicine.

It states:
"Their recommendation for acupuncture benefits ≤3 months is based, by their own admission, mostly on very low quality evidence and some low quality evidence. What does this mean? Mostly that the trials are not properly controlled or blinded. Given that acupuncture has a high placebo effect, this renders the results mostly worthless. Even within a pure EBM framework, this is an extremely weak justification for a recommendation."​

Isn't this the case for exercise, CBT and ACT as well?

https://sciencebasedmedicine.org/uk-recommendations-wrong-on-acupuncture/
 
Jonathan Edwards said:
Ernst again completely misses the point that exercise and ACT are just as bogus as acupuncture.
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Michiel Tack said:
Same here in this article from Science based medicine.
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Also the Twitterer I quoted above.

It's noticeable that they rightly criticize how evidence was evaluated for alternative interventions in a systematic review or a meta-review used for a guidance, but they skip the very same problem with other interventions in the same review/ guidance.

Perhaps someone should make them aware of this omission in a factual, not too challenging manner?

(Why I think it needs to be "not too challenging"; i.e. why the people quoted above don't apply the same standards to interventions not classified as 'alternative' is another topic.)

Edited for clarity.
 
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MSEsperanza said:
Also the Twitterer I quoted above.

Perhaps someone should tell them in a factual, not too challenging manner?

(Why I think it needs to be "not too challenging"; i.e. why the people quoted above don't apply the same standards to interventions not classified as 'alternative' is another topic. I see they are specialists in assessing alternative medicine so it's not their focus. However, when they rightly criticize how evidence was evaluated for alternative interventions in a systematic review or a meta-review used for a guidance, it's noticeable if they skip the very same problem with other interventions in the same review/ guidance)
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I submitted the following comment to Ernst's blog:

There will be many critical responses to NICE’s recommendation of acupuncture, and rightly so: the evidence it is based on is very weak.

But equally, why are the recommendations of exercise and psychotherapy not being criticized?

Like acupuncture, the evidence that NICE reviewed for these interventions mostly comprised low to very low quality studies, first and foremost non-blinded trials with subjective outcomes. Even then, most differences in outcomes between control and active groups were clinically insignificant (under the thresholds for a minimally important difference), e.g. varying by just a few points or decimals on questionnaires.

A critical appraisal of the guideline needs to take all of the evidence into account — not only that which receives the most attention –.
​
 
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Jonathan Edwards said:
Ernst again completely misses the point that exercise and ACT are just as bogus as acupuncture.
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Yeah the issues are far from limited to acupuncture, making it an odd item to focus on. Then again, if a process manufactures positive evidence for pseudoscience, all that tells you is that this process cannot distinguish between sham and real medicine, is highly manipulable for outcome-seeking purposes.

Which frankly is the only reasonable conclusion to make from this. We know for a fact that the substance of the "interventions" is irrelevant using such weak methodology, it could just as well be healing crystals or living barefoot. The only reason sham acupuncture or other sham controls fail is very likely because the research bias doesn't weakly tip the scale like it does when they want it to work.
 
cassava7 said:
I submitted the following comment to Ernst's blog:

There will be many critical responses to NICE’s recommendation of acupuncture, and rightly so: the evidence it is based on is very weak.

But equally, why are the recommendations of exercise and psychotherapy not being criticized?

Like acupuncture, the evidence that NICE reviewed for these interventions mostly comprised low to very low quality studies, first and foremost non-blinded trials with subjective outcomes. Even then, most differences in outcomes between control and active groups were clinically insignificant (under the thresholds for a minimally important difference), e.g. varying by just a few points or decimals on questionnaires.

A critical appraisal of the guideline needs to take all of the evidence into account — not only that which receives the most attention –.
​
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Ernst replied to my comment:

“But equally, why are the recommendations of exercise and psychotherapy not being criticized?”
In case you’ve missed it: this blog is on so-called alternative medicine (SCAM).
​
ETA: Per Ernst [1],

Complementary and alternative medicine is defined as "diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine."
​
Exercise and psychotherapy highlight an important issue with this definition. They are mainstream and orthodox in Western societies, with the effect that they (and commonly accepted therapies on this side of the world) become a blind spot of ours when they are used to treat ailments for which they are not effective -- and possibly harmful --.

[1] Ernst E. The role of complementary and alternative medicine. BMJ. 2000;321(7269):1133-1135. doi:10.1136/bmj.321.7269.1133
 
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