Have you been taking painkillers for more than several months? Pain is one of the most common complaints we see and manage. People are often resigned to the fact that they should try to tolerate it, or accept that medication they have been prescribed long term is the only option.
This month there was a change to the NICE guidelines for the management of chronic pain conditions. Chronic pain refers to pain lasting several months and covers conditions such as fibromyalgia, headache, primary musculoskeletal or visceral (organ) pain. The organisation now recommend treatment with antidepressants, talking therapies, exercise and acupuncture, as opposed to medication containing opioids or other addictive substances.
It has long been known that opioids are less effective in treating long term pain than short term pain, and are associated with addiction. You might have noticed that medicine packets containing opioids such as Cocodamol, carry warnings to use them for 3 days only. It is well known that addictions are easily formed quickly and without the patient’s awareness. The usual scenario is that increasing doses are required to have any effect, pain then increases, the underlying cause of the pain is not managed, as well as side effects from the opioids. Patients then require other medications to deal with the side effects from opioids such as nausea, constipation, mood changes, fatigue and insomnia. The withdrawal process can be lengthy and distressing.
There are many medical and non-medical alternatives to opioids including natural food supplements, postural management, physiotherapy, active relaxation, yoga/pilates and local therapies such as ultrasound, infections, muscle taping, creams and gels.
Guidelines recommend regular clinical assessments in cases where pain medication is required on a long term basis.
Health professionals should:-
‘Carry out regular clinical reviews to assess and monitor the effectiveness of the treatment. Each review should include an assessment of:
Impact on lifestyle, daily activities (including sleep disturbance) and participation
Physical and psychological wellbeing
Continued need for treatment’.
There are often several factors involved in the cause of the pain, as well as several different types of pain, such as nerve pain or bone pain. For example, bone pain caused by injury might cause a change in posture or gait which leads to muscular pain elsewhere. This is why an individualised approach to pain management is essential. Also, your medical history and any other medication you take might influence prescribing choice.
Neuropathic or nerve pain is particularly difficult to live with and treat because of the range of causes and symptoms. Therefore, an accurate assessment of the cause of the pain is important before beginning medications, supplements, or lifestyle changes.
Medical treatments for neuropathic pain include drugs originally developed as antidepressants such as tricyclics (e.g. Amitriptylline), selective serotonin reuptake inhibitors (e.g. Sertraline) or sertononin-norepinephrine reuptake inhibitors (e.g. Duloxetine). They were included in guidelines for management of nerve pain some time ago and have several benefits. As is the case with all medicines, they can have side effects ranging from a dry mouth to nausea.
Other medical treatments include drugs developed as antiepileptics such as Carbamazepine and Gabapentin. These classes of drug come with a risk of side effects such as fatigue or dizziness. Antidepressants and antiepileptics may take several weeks to work, so you might need advice on how to cope before the drug takes effect. Side effects often become better tolerated as the body adapts after 4 weeks. It is important to keep a diary of symptoms, anything you think might have helped or made the pain worse, and any side effects.
Topical treatments include Capsaicin cream, derived from chilli peppers, as well as standard anti-inflammatory gels including Diclofenac.
Off label prescribing
A common barrier to pain management is the prescription of unlicensed drugs, due to limited cost effectiveness or evidence. Off label prescribing means that a drug is prescribed for a condition that it is not licensed for. For example, Capsaicin cream is currently licensed for treatment of osteoarthritic pain but not localised neuropathic pain. However, because it has more recently been found to relieve local nerve pain, it can be prescribed in an unlicensed manner. At the RoC clinic, following a thorough pain assessment, we can prescribe unlicensed drugs when appropriate i.e. if they are safe and effective in your case.
Guidance for patients during a pain assessment
Guidance for patients has been published, which can help you during a pain assessment (2). You should consider these questions when discussing pain management with any health professional. You should remember that there are always alternatives to any drug you are offered, and feel comfortable with asking about them.
- What is causing the pain?
- Can you tell me more about neuropathic/bone/muscular etc pain?
- What can I do to manage the pain?
- Why have you decided to offer me this particular type of treatment?
- Why are you offering me an antidepressant or an antiepileptic drug for my pain?
- Can you tell me more about off-label (unlicensed) drugs?
- What are the possible benefits and risks of taking this particular drug?
- What should I do if I start to get side effects?
- What sort of improvements might I expect in my symptoms and everyday life?
- When should I take my medication?
- When should I start to feel better, and what should I do if I don’t start to feel better by then?
- Why is the dose being increased or decreased?
- How long will I need to take the medication for?
- Might I have problems when I stop taking the medication?
- What should I do if the pain becomes unbearable?
- What other options are available to me, apart from drugs?
- When will my next appointment with you be?
Do not suffer in silence or tolerate medications that you are not comfortable with. You might need help from a healthcare professional other than a doctor, for example, a physiotherapist, or referral to a specialist pain service. If this is the case, any medical professional will be able to refer you appropriately.
Sources of support
It is recognised that pain has an impact on all areas of functioning, from employment, to relationships and sleep.
www.painuk.org provides a list of charities aiming to help you improve your quality of life.
Pain Concern have a helpline 03001230789
National Institute for Health and Care Excellence (NICE) April 2021. Chronic pain (primary and secondary) in over 16s: assessment of chronic pain and management of chronic primary pain.
National Institute for Health and Care Excellence (NICE) November 2013. Last updated September 2020. Neuropathic pain in adults: pharmacological management in non-specialist settings