NICE published new guidance in April 2021 on the management of chronic primary pain. This is defined pain when there is no clear underlying cause.

Chronic secondary pain, on the other hand, is when the pain is caused by an underlying condition such as osteoarthritis, rheumatoid arthritis, ulcerative colitis or endometriosis, but this is not covered by the guideline.

The guidance recommends exercise programmes for managing chronic primary pain, as well as encouraging individuals to remain physically active for longer-term health benefits. Psychological therapies such as cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT), as well as acupuncture, delivered by an appropriately trained practitioner, can also be recommended, it says.

It is recommended that some commonly used medicines are not initiated to manage chronic primary pain. These include opioids, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, antipsychotics and gabapentinoids (e.g. gabapentin and pregabalin). This is because there is a lack of evidence for these medicines in improving a person’s quality of life and they may cause more harm than benefit, including addiction.

An antidepressant (amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline) can be considered for people aged 18 years and over to manage chronic primary pain, as is the case with Mrs Williams. The prescriber should have a full discussion about the benefits and possible harms with the patient before prescribing an antidepressant. Antidepressants may help with quality of life, pain, sleep and any psychological distress, even if there is no diagnosis of depression.