Patients with chronic pain should not be prescribed opioids as they could be ‘harmful’, new NICE guidelines says.

Instead, alternatives such as certain antidepressants, an exercise programme, CBT or acupuncture should be considered a possible treatments.

Published today, the long-awaited draft guidance says healthcare professionals should avoid prescribing commonly used medicines including opioids and gabapentinoids because there was limited evidence of their effectiveness in managing chronic pain.

However, there was evidence that they could be ‘harmful’ to patients and cause addiction, NICE added.

The guidance, which is open for consultation until 14 August, said: ‘The lack of evidence for effectiveness of opioids, along with evidence of long-term harm, persuaded the committee to recommend against opioid use for people with chronic primary pain.

‘Although there were limitations, evidence from non-randomised studies on the long-term use (more than six months) of opioids for chronic pain suggested an increased risk of dependence.’

It added: ‘Based on their experience, the committee agreed that even short-term use of opioids could be harmful for a chronic condition.’ 

NICE said healthcare professionals should not offer the following to patients aged 16 or over with chronic primary pain - defined as pain that persists or recurs for more than three months - ‘by any route’:

  • opioids
  • non-steroidal anti-inflammatory drugs
  • benzodiazepines
  • anti-epileptic drugs including gabapentinoids, unless gabapentinoids are offered as part of a clinical trial for complex regional pain syndrome
  • local anaesthetics, by any route, unless as part of a clinical trial for complex regional pain syndrome
  • local anaesthetic/corticosteroid combinations
  • paracetamol
  • ketamine
  • corticosteroids
  • antipsychotics

Prescribers should explain the ‘risks of continuing’ to those already taking any of these medicines, the document said.

It added: ‘If a shared decision is made to stop antidepressants, opioids, gabapentinoids or benzodiazepines, be aware of the problems associated with withdrawal.’

It is separately developing a guideline on medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management, but this is not expected until November 2021.

When assessing all types of chronic pain, NICE advised that prescribers ask a series of questions of patients and develop a care plan with the patient to suit their needs, fostering 'a collaborative supportive relationship'.

Non-pharmacological management of chronic pain could include a 'supervised group exercise programme', acceptance and commitment therapy (ACT) or cognitive-behavioural therapy (CBT); or a course of acupuncture or dry needling, the guideline said.

The document acknowledged that the change in guidance 'will involve a change of practice for some providers' and that 'to fully implement these recommendations for people with chronic pain, longer consultations or additional follow-up may be needed to discuss self management and treatment options'.

NICE also recommended futher research into the effectiveness of:

  • pain management programmes;
  • mindfulness therapy;
  • CBT for insomnia related to pain; and
  • gabapentinoids and local anaesthetics for complex regional pain syndrome.

The updated guidance follows Public Health England's landmark review into prescription drug addiction, published last year, which concluded that one in four adults - over 11m adults in England - received a prescription for antidepressants, opioids, gabapentinoids, benzodiazepines or z-drugs in the previous year.

A version of this story first appeared in our sister title Pulse.