By Pat Anson, PNN Editor

Doctors in the United Kingdom are being advised not to prescribe any type of painkiller to patients suffering from fibromyalgia, chronic headache, Complex Regional Pain Syndrome (CRPS), chronic musculoskeletal pain and other types of “primary chronic pain” for which there is no known cause.   

Those conditions should be treated with exercise, cognitive behavioral therapy (CBT), acupuncture and antidepressants, according to new guidelines released by the UK’s National Institute for Health and Care Excellence (NICE). The NICE guideline is far more strict on the use of analgesics than current treatment guidelines in the U.S. and Canada.

The recommendation against using painkillers goes beyond just opioids, and includes many widely used pain relievers such as paracetamol (acetaminophen), non-steroidal anti-inflammatory drugs (NSAIDs), gabapentinoids and corticosteroids, as well as benzodiazepines such as Valium and Xanax.

“There is little or no evidence that they make any difference to people’s quality of life, pain or psychological distress, but they can cause harm, including possible addiction,” NICE said in a statement.

The guideline says antidepressants such as duloxetine (Cymbalta) and fluoxetine (Prozac) “can be considered” for adults 18 and over with chronic primary pain, even when there is no diagnosis of depression. NICE said antidepressants may help with quality of life, pain, sleep and psychological distress.

“This guideline is very clear in highlighting that, based on the evidence, for most people it’s unlikely that any drug treatments for chronic primary pain, other than antidepressants, provide an adequate balance between any benefits they might provide and the risks associated with them,” Dr. Paul Chrisp, director of NICE’s Centre for Guidelines, said in a statement.

“People who are taking medicines to treat their chronic primary pain which aren’t recommended in the guideline should ask their doctor to review their prescribing as part of shared decision making. This could involve agreeing a plan to carry on taking their medicines if they provide benefit at a safe dose and few harms, or support for them to reduce and stop the medicine if possible.”

The NICE guideline sticks to more traditional recommendations for treating “chronic secondary pain” for which there is a known underlying cause, such as osteoarthritis, rheumatoid arthritis, ulcerative colitis and endometriosis. Pain management for palliative care is not covered in the guideline.

‘Patently Ridiculous’

Although a draft version of the NICE guideline was released last August, pain sufferers were startled by some of the final recommendations, especially those for acupuncture, CBT and exercise.

“The idea that a run around the block will zap the torment of people in chronic pain is patently ridiculous. It doesn’t do a damned thing for my hip,” said James Moore, a UK disability activist who uses a wheelchair. “Did none of the people who contributed to this not read it through this guidance and spot any of the gaping holes in its logic? How is it that I can see them and they can’t?”

“I fear the consequences for those with unsympathetic GPs who suddenly find themselves without medication that may work for them,” Moore wrote in the Independent. “This guidance urgently needs a rethink. Sadly, there may be torture looming for those in torment before we get one.”

The NICE guideline is at odds with recent studies that found antidepressants are minimally effective as pain relievers and often have adverse side effects. A common complaint of pain patients who take duloxetine, for example, is how quickly they became dependent on the drug and have severe withdrawal symptoms when they stop taking it.

The UK guideline also differs from treatment recommendations made by U.S. health agencies. The FDA and CDC recommend gabapentinoids for fibromyalgia, and acetaminophen and NSAIDs for low back pain and migraine.   

The CDC is currently in the process of updating and possibly expanding its opioid guideline to include recommendations for opioid tapering, short-term acute pain, migraine and other pain conditions.