Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain

Impact on NHS workforce and resources

The NICE guideline on chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain was published in April 2021. The guideline recommendations have been reviewed for their potential impact on the NHS workforce and resources.

The guideline covers assessing all chronic pain (chronic primary pain, chronic secondary pain, or both) and managing chronic primary pain in people aged 16 years and over.

The recommendations in the guideline were developed before the COVID-19 pandemic.

Recommendations likely to have an impact on resources

The recommendations most likely to have the greatest resource impact nationally (for England) are listed below.

• Offer a supervised group exercise programme to people aged 16 years and over to manage chronic primary pain (recommendation 1.2.1).
• Consider acceptance and commitment therapy (ACT) or cognitive–behavioural therapy (CBT) for pain for people aged 16 years and over with chronic primary pain (recommendation 1.2.3).
• Consider a course of acupuncture or dry needling for people aged 16 years and over to manage chronic primary pain (recommendation 1.2.5).
• Consider an antidepressant, for people aged 18 years and over to manage chronic primary pain, after a full discussion of the benefits and risks (recommendation 1.2.7).
• Do not initiate certain pharmacological interventions in people aged 16 years and over to manage chronic primary pain (recommendation 1.2.10).
• If a person with chronic primary pain is already taking any of the medicines listed in recommendation 1.2.10, review the prescribing as part of shared decision making (recommendation 1.2.11).

Context

Chronic pain (sometimes known as long-term pain or persistent pain) is pain that lasts for more than 3 months. Pain can be secondary to (caused by) an underlying condition (for example, osteoarthritis, rheumatoid arthritis, ulcerative colitis, endometriosis). Chronic pain can also be primary. Chronic primary pain has no clear underlying condition, or the pain (or its impact) appears to be out of proportion to any observable injury or disease. The decisions about the search for any injury or disease that may be causing the pain, and about whether the pain or its impact are out of proportion to any identified injury or disease, are matters for clinical judgement in discussion with the patient.

The mechanisms underlying chronic primary pain are only partially understood and the definitions are fairly new. All forms of pain can cause distress and disability, but these features are particularly prominent in presentations of chronic primary pain. Chronic primary pain frequently coexists with other secondary pains and there are frequently mixed mechanisms involved in causing symptoms. Both aspects need addressing effectively to achieve therapeutic benefit and patient satisfaction. The guideline is consistent with the ICD-11 definition of chronic primary pain.

Chronic pain services are commissioned by clinical commissioning groups; in some areas this will be through an integrated care system and NHS England. Providers are NHS hospital trusts, primary care providers and community services.

Resource impact

The net financial impact of these recommendations will be determined by the resources needed to support changes to the medicines prescribed for chronic primary pain. Based on the assumptions used in the financial model, the net estimated financial impact of implementing the guideline per 100,000 population in the next 5 years is a saving of around £200 in year 1 rising to a saving of around £1,100 in year 5, as set out in the table below.

Estimated annual saving of implementing the guideline per 100,000 population

The cash saving for clinical commissioning groups per 100,000 population is estimated to be around £83,000 by year 5, with £30,600 attributable to the incident population and £52,200 attributable to the prevalent population. This is due to the reduced use of higher cost medicines for people with chronic primary pain.

Investment will be needed at a local level to generate these savings by changing prescribing patterns, and costs will vary locally depending on current practice and prescribing patterns. The cash costs for community service providers per 100,000 population, commissioned by integrated care systems, clinical commissioning groups or strategic transformation partnerships, are estimated to be around £82,000 by year 5, with £9,200 attributable to the incident population and £72,500 attributable to the prevalent population. This results from increases in psychological services, acupuncture and group exercise programmes. These costs do not include any additional training costs that may be needed to support implementation of the guideline, but it is recognised that there may be further financial and resource implications arising from this.

Support to put the recommendations into practice

Assessment and management

The main focus of the guideline is chronic primary pain. This is pain that persists or recurs for longer than 3 months for which no underlying condition adequately accounts for the pain or its impact. The section of the guideline on assessment also covers chronic pain caused by an underlying condition (chronic secondary pain) to emphasise the importance of distinguishing between people with an underlying condition driving their experience of pain and those with chronic primary pain. The management section covers interventions to support people with chronic primary pain. It is acknowledged that current availability and delivery of pain services is variable, and that new services may need to be commissioned, meaning that implementation of the recommendations may not be immediate.

Support from NICE

• We have published a visual summary on the recommendations for chronic pain (primary and secondary).
• The guideline should be used alongside NICE guidelines for other chronic pain conditions, including headaches, low back pain and sciatica, rheumatoid arthritis, osteoarthritis, spondyloarthritis, endometriosis, neuropathic pain and irritable bowel syndrome.
• It should also be used alongside our guidelines on medicines management and patient and service user care.

Support from outside NICE

• NHS England and NHS Improvement have developed acomprehensive model of personalised care, which helps to establish a whole-population approach to supporting people of all ages and their carers to manage their physical and mental health and wellbeing, build community resilience, and make informed decisions and choices when their health changes.
• NHS England and NHS Improvement are developing a model of integrated musculoskeletal (MSK) healthcare to improve and sustain delivery of evidence-informed, personalised, high-quality, integrated MSK healthcare of value to all. Workstreams will cover:
  • restoration and optimisation of diagnostics; orthopaedics; rheumatology; spinal services; falls, fragility fractures and osteoporosis management; and paediatric MSK
  • restoration of primary care community MSK provision
  • data, validation, and coding
  • outpatients optimisation
  • supporting those with long-term MSK conditions.
• The Getting It Right First Time (GIRFT) workstream on rheumatology have published recommendations for improving pathways of care which will support the implementation of this guideline, and those for other chronic pain conditions.
• BeeFree is a collection of web-based resources, support and training for patients, clinicians and volunteers to assist those with chronic pain and mental health issues. It is a collaboration between patients and professionals from the Health Foundation’s Q Lab, Mind and 4 academic and healthcare organisations.
• The Musculoskeletal Health Questionnaire (MSK-HQ) is a single musculoskeletal outcome measure that can be used throughout the healthcare pathway and with patients with different musculoskeletal conditions.

Prescribing medicines for chronic pain

The guideline recommends a move away from potentially harmful medicines, to predominately non-pharmacological treatments for primary chronic pain. People who are taking medicines that are not recommended in the guideline should have a review with their GP as part of shared decision making. This could involve agreeing a shared plan for continuing their medicine safely if the person reports benefit at a safe dose and few harms, or support to reduce and stop the medicine if possible. When making shared decisions about whether to stop antidepressants, opioids, gabapentinoids or benzodiazepines, the guideline advises that any problems associated with withdrawal should be discussed.

This approach is supported by the British Pain Society, the Faculty of Pain Management, the Royal College of General Practitioners and the Chronic Pain Policy Coalition (see their statement regarding patients already on medication).

Support from NICE

• NICE has published information to support shared decision making and a guideline on shared decision making.
• NICE is producing a guideline on medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults, expected to publish in April 2022.
• NICE medicines and prescribing associates have received training resources and shared examples of good practice supporting the guideline recommendations. They are working in their local health economies to implement the guideline, reduce inappropriate prescribing and develop new pathways of care.

Support from outside NICE

• NHS England and NHS Improvement are coordinating a programme to implement recommendations in Public Health England’s Prescribed medicines review, and support the Government’s Good for you, good for us, good for everybody: a plan to reduce overprescribing to make patient care better and safer, support the NHS, and reduce carbon emissions review. They are working closely with relevant arm's-length bodies to ensure cross-system improvements are identified and implemented over the next 12 to 18 months. The programme aims to deliver cross-system improvements in the following areas:
  • Increasing the availability and use of data on the prescribing of medicines that can cause dependence or withdrawal.
  • Enhancing clinical guidance and improving adherence to it.
  • Improving information for patients and carers and increasing informed choice and shared decision making between clinicians and patients.
  • Improving the support available from the healthcare system for patients experiencing dependence on, or withdrawal from, prescribed medicines.
  • Supporting further research on the prevention and treatment of dependence on, and withdrawal from, prescribed medicines.
• The programme will be delivered alongside NHS Long Term Plan commitments on personalised care, shared decision making, social prescribing and the rollout of primary care network pharmacists and link workers.
• The service specification for Structured medication review and medicines optimisation sets out guidance for primary care networks implementing the structured medication review and medicines optimisation service, as per the requirements set out in the Network Contract Directed Enhanced Service (DES) Specification for 2020/21, which states that primary care networks must have due regard to this guidance when delivering the service. It includes the principles of undertaking a structured medication review and should be read alongside the DES Specification and the Network Contract DES.
• The Faculty of Pain Management’s Opioids Aware, is an online resource for prescribers that provides information to support safe and effective prescribing decisions.

Note that external websites and resources referred to in this statement have been identified as potentially useful resources to help implement specific recommendations from the guideline. NICE has not made any judgement about the methodology, quality or usability of the websites or resources.