Drugs for chronic pain

In August 2020, the National Institute for Health and Care Excellence (NICE) published the draft guidance on chronic pain, which perhaps controversially advises against the use of all drugs except antidepressants.1 The committee cite an absence of evidence on effectiveness, their experience, information in product summaries, and the established or possible risk of harm as justification for their negative recommendations. Public reaction perhaps reflects the assumption the guidelines apply to all chronic pain conditions. This is not the case. The guideline explicitly does not cover pain conditions that have existing NICE guidelines including headache, low back pain (LBP) and irritable bowel syndrome (IBS).1–6 This creates an interesting tension, since some recommendations are discordant (Box 1). | Drug class | Draft NICE guideline: chronic pain in over 16s, August 20201 | NICE guideline: low back pain and sciatica in over 16s, updated September 20205 | NICE guideline: headache in over 12s, updated November 20154,a | NICE guideline: irritable bowel syndrome in adults, updated April 20176 | NICE guideline: osteoarthritis, updated February 20148 | |:--------------------------- | --------------------------------------------------------------------------------------------------------------- | ---------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------- | -------------------------------------------------------------------------------------------- | | Opioids | Do not offer | Do not offer | Be alert to the possibility of medication overuse headache in people whose headache developed or worsened while they were taking the following drugs for ≥3 months: | No specific recommendation | If paracetamol or topical NSAIDs are insufficient consider the addition of opioid analgesics | | NSAIDs | Do not offer | Consider oral NSAIDs (conditions apply) | No specific recommendation | Where paracetamol or topical NSAIDs are ineffective consider substitution with (or addition of) an oral NSAID/COX-2 inhibitor | | Paracetamol (acetaminophen) | Do not offer | Do not offer paracetamol alone | No specific recommendation | Consider offering paracetamol in addition to core treatments. | | Antidepressants | Consider an antidepressant, either duloxetine, fluoxetine, paroxetine, citalopram, sertraline, or amitriptyline | Do not offer SSRIs, serotonin–norepinephrine reuptake inhibitors, or tricyclic antidepressants | Consider amitriptyline for the prophylactic treatment of migraine | Consider TCAs as second line treatment for people with IBS. Consider SSRIs for people with IBS only if TCAs are ineffective | No specific recommendation | | Anticonvulsants | Do not offer | Do not offer | Do not offer gabapentin for prophylactic management of migraine | No specific recommendation | No specific recommendation | Box 1. Concordance between drug recommendations in draft NICE chronic pain guideline and NICE guidelines for low back pain, headache, irritable bowel syndrome, and osteoarthritis The guideline committee used the International Classification …