Chronic pain syndrome: assessment, self-management and what NICE recommends

NICE's guideline covers all types of chronic pain, which it defines as pain that persists or recurs for more than 3 months. It distinguishes chronic primary pain, in which no underlying condition adequately accounts for the pain or its impact, from chronic secondary pain, in which an underlying condition does, and notes the two can coexist. It asks clinicians to think about chronic primary pain when there is no clear underlying cause, or when the pain or its impact is out of proportion to any observable injury or disease, particularly when it is causing significant distress and disability.

It also advises recognising that an initial diagnosis of chronic primary pain may change with time and should be re-evaluated if the presentation changes. For underlying conditions, such as arthritis or low back pain, it refers clinicians to the guideline for that condition.

NICE advises a person-centred assessment of what contributes to the pain and how it affects life, covering lifestyle and day-to-day activities including work and sleep disturbance, physical and psychological wellbeing, stressful life events including previous or current trauma, any substance misuse, social interaction and relationships, and difficulties with employment, housing, income or other social concerns. It asks clinicians to explore strengths as well as impact, including skills for managing pain and what helps when pain is hard to control.

It also asks that people are told that symptoms will fluctuate and flare-ups may occur, that a reason for the pain or a flare-up may not be identified, that pain may not improve or may get worse and need ongoing management, and that quality of life can improve even if pain stays the same. When test results are normal or negative, NICE asks clinicians to be sensitive to the risk of invalidating the person's experience of pain.

NICE advises agreeing a care and support plan with the person, exploring priorities, abilities and goals, what they already find helpful, and their preferred approach to treatment, and explaining the evidence for benefits, risks and uncertainties of all options. For people aged 16 to 25 it asks clinicians to consider age-related differences, family dynamics and the impact on education and social and emotional development.

For chronic primary pain, NICE advises offering a supervised group exercise programme to people aged 16 and over and encouraging them to remain physically active for longer-term general health. It advises considering acceptance and commitment therapy (ACT) or cognitive behavioural therapy (CBT) for pain, delivered by suitably trained professionals. It also suggests considering a single course of acupuncture or dry needling in certain settings and within a limit of 5 hours of professional time.

It advises against offering biofeedback, and against TENS, ultrasound or interferential therapy because there is no evidence of benefit for chronic primary pain.

NICE advises considering an antidepressant (amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline) in adults 18 and over after a full discussion of benefits and harms, and says to explain it is offered because these medicines may help with quality of life, pain, sleep and psychological distress even without depression. It advises seeking specialist advice for 16 to 17-year-olds.

It also advises not starting a list of medicines to manage chronic primary pain in people 16 and over: antiepileptic drugs including gabapentinoids (except in a clinical trial for complex regional pain syndrome), antipsychotics, benzodiazepines, corticosteroid trigger point injections, ketamine, local anaesthetics (except in a trial), NSAIDs, opioids and paracetamol. If someone is already taking these, NICE advises a shared review, explaining the lack of evidence, agreeing a plan to continue safely if they report benefit with few harms, or supporting them to reduce and stop if benefit is small or harm significant, and discussing withdrawal problems. Never stop a prescribed medicine suddenly without advice. This guidance concerns chronic primary pain; other types of pain may be managed differently.

The British Pain Society says people with chronic pain may be able to attend a specialist pain clinic for assessment and possible pain management, together with advice on living a fuller life despite pain. Clinics vary in what they offer, not every hospital has one, and a GP can refer you. Some have teams of doctors, psychologists, nurses, physiotherapists and occupational therapists.

It describes a pain management programme as a psychologically based rehabilitative treatment for chronic pain unresolved by other treatments, delivered in a group by an interdisciplinary team. For most people, it says, attending reduces the disability and distress caused by chronic pain by teaching physical, psychological and practical techniques, and pain relief is not the primary goal. Referral is usually via a local pain clinic.