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Management of chronic pain

Assessment

  • A concise history, examination and biopsychosocial assessment, identifying pain type (neuropathic/nociceptive/mixed), severity, functional impact and context should be conducted in all patients with chronic pain. This will inform the selection of treatment options most likely to be effective
  • Referral should be considered when non-specialist management is failing, chronic pain is poorly controlled, there is significant distress, and/or where specific specialist intervention or assessment is considered
  • A compassionate, patient-centred approach to assessment and management of chronic pain is likely to optimise the therapeutic environment and improve the chances of successful outcome

Supported self management

  • Self management resources should be considered to complement other therapies in the treatment of patients with chronic pain
  • Healthcare professionals should signpost patients to self help resources, identified and recommended by local pain services, as a useful aide at any point throughout the patient journey. Self management may be used from an early stage of a pain condition through to use as part of a long term management strategy

Pharmacological therapies

  • Patients using analgesics to manage chronic pain should be reviewed at least annually, and more frequently if medication is being changed, or the pain syndrome and/or underlying comorbidities alter

Non-opioid analgesics (simple and topical)

  • Non-steroidal anti-inflammatory drugs (NSAIDs) should be considered in the treatment of patients with chronic non-specific low back pain
  • Cardiovascular and gastrointestinal risk needs to be taken into account when prescribing any NSAID
  • Paracetamol (1000–4000 mg/day) should be considered alone or in combination with NSAIDs in the management of pain in patients with hip or knee osteoarthritis in addition to non-pharmacological treatments
  • Topical NSAIDs should be considered in the treatment of patients with chronic pain from musculoskeletal conditions, particularly in patients who cannot tolerate oral NSAIDs
  • Topical capsaicin patches (8%) should be considered in the treatment of patients with peripheral neuropathic pain when first line pharmacological therapies have been ineffective or not tolerated
  • Topical lidocaine should be considered for the treatment of patients with postherpetic neuralgia if first line pharmacological therapies have been ineffective
  • Topical rubifacients should be considered for the treatment of pain in patients with musculoskeletal conditions if other pharmacological therapies have been ineffective

Opioids

  • Strong opioids should be considered as an option for pain relief for patients with chronic low back pain or osteoarthritis, and only continued if there is ongoing pain relief. Regular review is required
  • Patients prescribed opioids should be advised of the likelihood of common side effects such as nausea and constipation
  • All patients on strong opioids should be assessed regularly for changes in pain relief, side effects and quality of life, with consideration given to a gradual reduction to the lowest effective dose
  • It may be necessary to trial more than one opioid sequentially, as both effectiveness and side effects vary between opioids
  • Opioid rotation should be considered for chronic pain that is likely to respond to opioids, if there are problems with efficacy or side effects
  • Signs of abuse and addiction should be sought at re-assessment of patients using strong opioids. Routine urine drug testing, pill counts or prescription monitoring should not be used to detect problem use
  • Currently available screening tools should not be relied upon to obtain an accurate prediction of patients at risk of developing problem opioid use before commencing treatment
  • There should be careful assessment of pre-existing risk factors for developing opioid misuse. In patients where opioid therapy is indicated, but there is an increased risk of iatrogenic opioid misuse, specialist advice should be sought. The minimal effective dose should be used to avoid increased problems of fracture and overdose that may occur on higher doses
  • Specialist referral or advice should be considered if there are concerns about rapid-dose escalation with continued unacceptable pain relief, or if >180 mg/day morphine equivalent dose is required

Anti-epilepsy drugs

  • Gabapentin (titrated up to at least 1200 mg daily) should be considered for the treatment of patients with neuropathic pain
  • Pregabalin (titrated up to at least 300 mg daily) is recommended for the treatment of patients with neuropathic pain if other first and second line pharmacological treatments have failed
  • Pregabalin (titrated up to at least 300 mg daily) is recommended for the treatment of patients with fibromyalgia
  • Flexible dosing may improve tolerability. Failure to respond after an appropriate dose for several weeks should result in trial of a different compound
  • Carbamazepine should be considered for the treatment of patients with neuropathic pain. Potential risks of adverse events should be discussed

Antidepressants

  • Patients with chronic pain conditions using antidepressants should be reviewed regularly and assessed for ongoing need and to ensure that the benefits outweigh the risks
  • Tricyclic antidepressants should not be used for the management of pain in patients with chronic low back pain
  • Amitriptyline (25–125 mg/day) should be considered for the treatment of patients with fibromyalgia and neuropathic pain (excluding HIV-related neuropathic pain)
  • It may be appropriate to try alternative tricyclic antidepressants to reduce the side effect profile
  • Duloxetine (60 mg/day) should be considered for the treatment of patients with diabetic neuropathic pain if other first or second line pharmacological therapies have failed
  • Duloxetine (60 mg/day) should be considered for the treatment of patients with fibromyalgia or osteoarthritis
  • Fluoxetine (20–80 mg/day) should be considered for the treatment of patients with fibromyalgia
  • Optimised antidepressant therapy should be considered for the treatment of patients with chronic pain with moderate depression
  • Depression is a common comorbidity with chronic pain. Patients should be monitored and treated for depression when necessary

Combination therapies

  • Combination therapies should be considered for patients with neuropathic pain (a pathway for patients with neuropathic pain can be found here).
  • In patients with neuropathic pain who do not respond to gabapentinoid (gabapentin/pregabalin) alone, and who are unable to tolerate other combinations, consideration should be given to the addition of an opioid such as morphine or oxycodone. The risks and benefits of opioid use needs to be considered

Psychologically based interventions

  • Healthcare professionals referring patients for psychological assessment should attempt to assess and address any concerns the patient may have about such a referral. It may be helpful to explicitly state that the aims of psychological interventions are to increase coping skills and improve quality of life when faced with the challenges of living with pain

Pain management programmes

  • Referral to a pain management programme should be considered for patients with chronic pain

Unidisciplinary education

  • Brief education should be given to patients with chronic pain to help patients continue to work

Behavioural therapies

  • Progressive relaxation or electromyographic biofeedback should be considered for the treatment of patients with chronic pain
  • Clinicians should be aware of the possibility that their own behaviour, and the clinical environment, can impact on reinforcement of unhelpful responses

Cognitive behavioural therapy

  • Cognitive behavioural therapy should be considered for the treatment of patients with chronic pain

Physical therapies

Manual therapy

  • Manual therapy should be considered for short term relief of pain for patients with chronic low back pain
  • Manual therapy, in combination with exercise, should be considered for the treatment of patients with chronic neck pain

Exercise

  • Exercise and exercise therapies, regardless of their form, are recommended in the management of patients with chronic pain
  • Advice to stay active should be given in addition to exercise therapy for patients with chronic low back pain to improve disability in the long term. Advice alone is insufficient
  • The following approaches should be used to improve adherence to exercise:
    • supervised exercise sessions
    • individualised exercises in group settings
    • addition of supplementary material
    • provision of a combined group and home exercise programme

Electrotherapy

  • Transcutaneous electrical nerve stimulation (TENS) should be considered for the relief of chronic pain. Either low or high frequency TENS can be used
  • Low level laser therapy should be considered as a treatment option for patients with chronic low back pain

Complementary therapies

Acupuncture

  • Acupuncture should be considered for short term relief of pain in patients with chronic low back pain or osteoarthritis

full guidelines available from…
Scottish Intercollegiate Guidelines Network, Gyle Square, 1 South Gyle Crescent, Edinburgh EH12 9EB (Tel – 0131 623 4720 )
www.sign.ac.uk/sign-136-management-of-chronic-pain.html

Scottish Intercollegiate Guideline Network. Management of chronic pain. Edinburgh: SIGN; 2014. (SIGN Guideline No. 136).
First included: February 2014.

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