Patient centred approach to treating chronic pain
Marc Sanders works in clinical practice as a chiropractor in London, as well as a postgraduate researcher at the University of Southampton’s Faculty of Medicine, where he is researching the integration of chiropractic care into healthcare systems, including the NHS. During the COVID-19 pandemic, he led several studies investigating the use of telehealth within chiropractic, exploring the efficacy of these ‘remote consultations’ from the patients’ and clinicians’ perspective. In addition to helping his patients to recover from a variety of conditions, he enjoys writing evidence-based healthcare articles to help improve public health and aims to increase awareness of what the chiropractic profession can offer for patients suffering from musculoskeletal conditions.
Overview to chronic pain
With the latest guidance from NICE advising a range of effective treatments for people with chronic primary pain, and additionally calling on healthcare professionals to recognise and treat a person’s pain as unique to them, healthcare professionals across all industries, including the chiropractic industry, are reviewing how they treat their patients [1].
The prevalence of chronic pain in the UK
In the UK, the prevalence of chronic pain is uncertain, but appears common, affecting approximately one-third to one-half of the population. The prevalence of chronic primary pain is unknown but is estimated to be between 1 and 6% in England [2].
For centuries, painkillers have been used to treat a wide range of conditions, and it’s no different today. From 2017 to 2018, 5.6 million adults in England (13% of the population) were prescribed with opioid pain medications [3]. The accessibility of painkillers, their low-cost margin and effectiveness, make them an easy solution for managing musculoskeletal pain. Yet, recent studies, including the new NICE guideline on chronic pain, are increasingly demonstrating that patients experiencing chronic back pain may be more responsive to other types of treatment. Our current, most-widely used treatments such as opioids, spinal injections and surgery are failing to address the burden of back pain disability. Musculoskeletal conditions are the number one cause of disability in the UK [4] [5], and this will likely continue to rise globally, as the years lived with disability caused by low back pain increased by 54% between 1990 and 2015 [6].
Furthermore, Public Health England (PHE) found that over half a million people have been taking opioid painkillers to treat chronic conditions, such as lower back pain, for more than three years. Experts have warned that opioid drugs are highly addictive, with over-the-counter medications such as paracetamol or ibuprofen being just as effective for chronic pain conditions [7]. Whilst painkillers are a viable option for managing high levels of pain short term, there are often safer and more effective options available for patients with chronic pain, which the new NICE guideline highlights. Yet, non-pharmacological treatment is still not being widely utilised.
Empowering patients
Each individual’s pain experience is unique because it is influenced by different factors to somebody else. We know that someone’s experience of pain can be influenced by multiple factors including biological factors, mental health factors, such as depression and post-traumatic stress disorder, social factors, such as deprivation or lack of access to services, emotional factors, such as anxiety or previous trauma, and expectations and beliefs about pain. These factors should all be discussed as part of an initial assessment so that the management strategies and treatments can be tailored to an individual according to the unique combination of factors that influence their pain. This is part of patient-centred care; it puts the individual person at the centre of care, addressing their individual needs. If these factors are not addressed as part of an initial assessment, it is often why one treatment or combination of treatments will work for one person with chronic pain, but not for another. There is a mismatch between the individual’s needs and the treatment(s) provided for them.
Managing chronic pain can be complex, however, with sufficient time spent to elicitate these influential factors, chronic pain can be better managed to improve the quality of life of each patient. Time spent in the assessment should also include the patient so that they can actively-participate in their care. Sharing information and education with a patient, allowing them to join in with the decision-making in terms of choice of the management options available to them, as well as giving them time to communicate their needs and concerns and explaining how their pain impacts different parts of their life and how different parts of their life influence their pain, are all very important.
The guideline highlights that whilst the tests that a person has undertaken to help rule in and rule out the causes of their pain may be normal or negative, healthcare professionals should not invalidate this person’s experience of their pain. Just because a cause isn’t known and tests do not show a clear cause, does not mean that a person’s pain experience isn’t real and having a negative impact on aspects of their life. When utilising exercise programmes as a treatment option for chronic primary pain, a person’s individual needs, preferences, and abilities with respect to their life and their choice of activities need to be discussed as part of their plan.
NICE guidance on chronic pain and drug treatment
The latest guidelines from NICE place a renewed emphasis on collaborative methods to treat chronic pain, using insights from both the healthcare professional and the patient. The guideline shows that based on the latest evidence, for the majority of people, it’s “unlikely that any drug treatments for chronic primary pain, other than antidepressants” have significant enough benefit to warrant the risks that are associated with them. The drug treatments that are available, except antidepressants, are therefore not the answer to treating chronic primary pain for most people.
Based on the current evidence, there is a wide variety of effective, non-pharmacological treatments for chronic pain, which include, exercise programmes, psychological therapies, CBT, acceptance and commitment therapy (ACT), and acupuncture. There is also a variety of treatments that should not be offered for chronic primary pain, which include, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, opioids, TENS, ultrasound, and interferential therapy. Healthcare professionals need to be aware of this guidance when developing a treatment plan for patients with chronic pain. These treatments which are not recommended because they have not been shown to make a significant difference to people’s quality of life, pain or psychological distress, can also cause harm, such as the possibility of addiction with some drug treatments.
For patients who are currently using drug treatments to help them manage their chronic primary pain, it is important that they do not stop taking medication without having suitable, safer and more effective treatments available to replace them. Therefore, if they are currently taking medication for their chronic primary pain, it is advisable for them to see their GP to discuss the available NHS and non-NHS treatment options in their area that they could add in as part of their plan of management of their pain. If a patient is taking a medication that is not mentioned in the new NICE guideline on chronic pain, it is also recommended for them to see their GP to review the prescribing of this medication so that they can make this informed treatment decision together.
The new decision could be to continue the medication if it is helping a patient to manage their pain, after weighing up the balance between the benefits and risks of the medication, or a GP could provide support to help gradually reduce and eventually stop using the medication, alongside the provision of alternative, more effective treatments for their pain. This is particularly important with medications where there is known withdrawal symptoms, and a GP can help to anticipate, manage, and understand these symptoms if the patient decides to reduce and stop using the medication.
The recommended guidelines are not there to rule out drug treatments for chronic primary pain completely, but they are there to ensure that drug treatment choices are carefully and judiciously made, given the known risks of many of well-known analgesic medications such as opioids. Whilst the potential risks of drug treatments for chronic pain may be well known to healthcare professionals, patients are not always aware of these, hence the emphasis on shared decision making with regards to drug treatments.
The need for more research
The NICE guideline summarised and assessed the evidence base for the treatment options that are currently available for chronic primary pain, and provided recommendations based on this evidence. Further research is required so that new and existing treatment options for chronic primary pain are assessed thoroughly and can then be catered to a person’s needs, therefore there is hope for additional treatment options for those who suffer from chronic primary pain that will become recommended in the future. The guideline recommends additional research into various types of therapy so that their effectiveness can be assessed for managing different aspects of chronic primary pain, including psychological therapies (mindfulness, CBT), manual therapies (soft tissue techniques, joint manipulation/mobilisation, acupuncture), pharmacological treatments (gabapentinoids, local anaesthetics), psychotherapy, social interventions, and electrical physical modalities (laser therapy, transcranial magnetic stimulation).
As an example, there is a lack of evidence (more studies need to be conducted) for manual therapies as a treatment for chronic primary pain, so recommendations could not be made by NICE. However, they concluded that the benefits, compared with usual care, were promising and there was no evidence of harm. Once further research studies have been conducted, future treatment options for chronic primary pain, such as manual therapies, may then be able to be recommended by NICE.
References:
[1] https://www.nice.org.uk/news/article/nice-recommends-range-of-effective-treatments-for-people-with-chronic-primary-pain-and-calls-on-healthcare-professionals-to-recognise-and-treat-a-person-s-pain-as-valid-and-unique-to-them
[2] https://www.nice.org.uk/news/article/nice-recommends-range-of-effective-treatments-for-people-with-chronic-primary-pain-and-calls-on-healthcare-professionals-to-recognise-and-treat-a-person-s-pain-as-valid-and-unique-to-them
[3] Taylor, S., Annand, F., Burkinshaw, P., Greaves, F., Kelleher, M., Knight, J., Perkins, C., Tran, A., White, M., Marsden, J., 2019. Dependence and withdrawal associated with some prescribed medicines: an evidence review [online]. Public Health England: London.
[4] Vos, T., Abajobir, A.A., Abate, K.H., Abbafati, C., Abbas, K.M., Abd-Allah, F., Abdulkader, R.S., Abdulle, A.M., Abebo, T.A., Abera, S.F. and Aboyans, V., 2017. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet, 390(10100), pp.1211-1259.
[5] Hay, S.I., Abajobir, A.A., Abate, K.H., Abbafati, C., Abbas, K.M., Abd-Allah, F., Abdulkader, R.S., Abdulle, A.M., Abebo, T.A., Abera, S.F. and Aboyans, V., 2017. Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet, 390(10100), pp.1260-1344.
[6] Krebs, E.E., Gravely, A., Nugent, S., Jensen, A.C., DeRonne, B., Goldsmith, E.S., Kroenke, K., Bair, M.J. and Noorbaloochi, S., 2018. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. Jama, 319(9), pp.872-882.
[7] Busse, J.W., Wang, L., Kamaleldin, M., Craigie, S., Riva, J.J., Montoya, L., Mulla, S.M., Lopes, L.C., Vogel, N., Chen, E. and Kirmayr, K., 2018. Opioids for chronic noncancer pain: a systematic review and meta-analysis. Jama, 320(23), pp.2448-2460.
