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Overview

Recommendations are graded [A][B][C][D] to indicate the strength of the supporting evidence. Good practice points [✓] are provided where the guideline development group wishes to highlight specific aspects of accepted clinical practice. 

For further information about the ‘strength’ of recommendations, see the SIGN 136 full guideline

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. [C]
  • 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. [B]
  • Cardiovascular and gastrointestinal risk needs to be taken into account when prescribing any non-steroidal anti-inflammatory drug. [B]
  • Paracetamol (1,000–4,000 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. [C]
  • Topical NSAIDs should be considered in the treatment of patients with chronic pain from musculoskeletal conditions, particularly in patients who cannot tolerate oral NSAIDs. [A]
  • 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. [A]
  • Topical lidocaine should be considered for the treatment of patients with postherpetic neuralgia if first-line pharmacological therapies have been ineffective. [B]
  • Topical rubifacients should be considered for the treatment of pain in patients with musculoskeletal conditions if other pharmacological therapies have been ineffective. [B]

Opioids

  • Opioids should be considered for short- to medium-term treatment of carefully selected patients with chronic non-malignant pain, for whom other therapies have been insufficient, and the benefits may outweigh the risks of serious harms such as addiction, overdose and death. [B]
  • At initiation of treatment, ensure there is agreement between prescriber and patient about expected outcomes (see Annex 4 of the full guideline). If these are not attained, then there should be a plan agreed in advance to reduce and stop opioids. [✓]
  • All patients on opioids should be assessed early after initiation, with planned reviews thereafter. These should be reviewed annually, at a minimum, but more frequently if required. The aim is to achieve the minimum effective dose and avoid harm. Treatment goals may include improvements in pain relief, function and quality of life. Consideration should be given to a gradual early reduction to the lowest effective dose or complete cessation. [✓]
  • Currently available screening tools should not be relied upon to obtain an accurate prediction of patients at risk of developing problem opioid use, but may have some utility as part of careful assessment either before or during treatment. [B]
  • Signs of abuse, addiction and/or other harms should be sought at reassessment of patients using strong opioids. [C]
  • All patients receiving opioid doses of >50 mg/day morphine equivalent should be reviewed regularly (at least annually) to detect emerging harms and consider ongoing effectiveness. Pain specialist advice or review should be sought at doses >90 mg/day morphine equivalent. [D]

Anti-epilepsy drugs

  • Gabapentin (titrated up to at least 1,200 mg daily) should be considered for the treatment of patients with neuropathic pain. [A]
  • 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. [A]
  • Pregabalin (titrated up to at least 300 mg daily) is recommended for the treatment of patients with fibromyalgia. [A] 
  • Flexible dosing may improve tolerability. Failure to respond after an appropriate dose for several weeks should result in trial of a different compound. [B]
  • Carbamazepine should be considered for the treatment of patients with neuropathic pain. Potential risks of adverse events should be discussed. [B]

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. [A]
  • Amitriptyline (25–125 mg/day) should be considered for the treatment of patients with fibromyalgia and neuropathic pain (excluding HIV-related neuropathic pain). [A]
  • 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. [A]
  • Duloxetine (60 mg/day) should be considered for the treatment of patients with fibromyalgia or osteoarthritis. [A]
  • Fluoxetine (20–80 mg/day) should be considered for the treatment of patients with fibromyalgia. [B]
  • Optimised antidepressant therapy should be considered for the treatment of patients with chronic pain with moderate depression. [B]
  • 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 in Annex 3 of the full guideline)[A]
  • 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. [A]

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. [C] 

Unidisciplinary education

  • Brief education should be given to patients with chronic pain to help patients continue to work. [C]

Behavioural therapies

  • Progressive relaxation or electromyographic (EMG) biofeedback should be considered for the treatment of patients with chronic pain. [C]
  • 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. [C]

Physical therapies

Manual therapy

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

Exercise

  • Exercise and exercise therapies, regardless of their form, are recommended in the management of patients with chronic pain. [B]
  • 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. [A]
  • The following approaches should be used to improve adherence to exercise:
    • supervised exercise sessions [B]
    • individualised exercises in group settings [B] 
    • addition of supplementary material [C]
    • provision of a combined group and home exercise programme. [B]

Electrotherapy

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

Complementary therapies

Acupuncture

  • Acupuncture should be considered for short-term relief of pain in patients with chronic low back pain or osteoarthritis. [A]

Sources of further information

British Complementary Medicine Association

British Pain Society

Chronic Pain Policy Coalition

Health and Social Care Alliance Scotland

Healthtalkonline Database

NHS Inform

Pain Association Scotland

Pain Concern

Pain Support

Pain UK

Scottish Intercollegiate Guidelines Network (SIGN). Management of chronic pain, Quick Reference Guide. Edinburgh: SIGN; first included December 2013. Revised edition published August 2019 (SIGN publication no. 136). 

Available from: www.sign.ac.uk/assets/sign136_qrg_2019.pdf

The copyright of Scottish Intercollegiate Guidelines Network (SIGN) guidelines is retained by SIGN. Subject to copyright statement (see www.sign.ac.uk/copyright-statement.html)

All SIGN guidelines are subject to regular review and may be updated or withdrawn. SIGN accepts no responsibility for the use of its content in this product/publication.

 

 

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