Patients with persistent pain often have a history of taking multiple medications with limited benefit. Patients (and clinicians) may also have unrealistic expectations of analgesia.
Recent National Institute for Health and Care Excellence (NICE) guidelines for the management of chronic pain have left GPs with limited medication options (NICE, 2021a). This has further complicated already challenging consultations. The intention of this article is to suggest five principles that can be applied to prescribing for all persistent pain in a primary care setting. This provides a framework for sustainable, patient-centred interactions that meet the needs of both patients and clinicians.
Shared decision making
Shared decision making is crucial to the pharmacological management of persistent pain. This involves discussion about risks, benefits and potential consequences to facilitate formulation of a plan that is acceptable to both patient and clinician (NICE, 2021b).
The medications offered to patients with persistent pain are not curative, are unlikely to provide more than 30–50% relief from pain and often help only a minority of people. However, a large number of patients will experience side effects and, once started, are likely to continue to take these medications even in the absence of any benefit (NICE, 2021a). Helping patients understand the risks and benefits of analgesia for chronic pain has clear benefits. Discussing options with patients improves safety, and is also associated with higher patient satisfaction, adherence and perceived practitioner empathy (Weiss et al, 2015).
Shared decision making allows patients to take ownership of their management. In pain clinic we see that well-informed patients are less likely to continue to take medications that are not helping and more likely to have realistic expectations of analgesia. This helps to avoid escalation of unnecessary medications and fraught consultations where the patient expects a curative treatment for their pain.
Sustainability
If a medication is prescribed for persistent pain it is likely that the patient will be taking that medication indefinitely. It is important to consider where prescribing decisions will leave the patient in future. For example, if prescribing a medication like codeine, where tolerance may be an issue, have you considered prescribing only for flares of pain so that it remains an effective treatment? It is also helpful to establish a maximum future dose for the medication at initiation and agree what would happen if this was reached. These conversations can prevent unchecked escalation of prescriptions and establish clear boundaries. This mean that patients are less likely to be surprised and upset in future when the dose can no longer be increased or it is time to discuss weaning.
It is also important to consider the impact of long-term use of these medications and communicate this to the patient. In particular, patients who have historically used high doses of opioids are at risk of consequences which can include immunocompromise and reduced fertility (Faculty of Pain Medicine of the Royal College of Anaesthetists, 2023). Other medications are not without risk, even amitriptyline may be associated with an increased incidence of dementia (Richardson et al, 2018).
Planning
Many of the medications used to manage chronic pain require titration and careful review to establish whether they are of benefit. It is important to have a robust plan in place when initiating these medications.
Titrate appropriately
One of the most common things we see in pain clinic is a failure to titrate appropriately. For example, many people have been on 10 mg of amitriptyline for years, far below the therapeutic dose for pain, with no clinical benefit.
Define success
With numbers needed to treat of up to 10 for 30% pain relief it is important that patients and clinicians consider critically whether analgesia is helpful (Wallit et al, 2015). This might involve the clinician exploring whether or the medications have made changes to patient's function or quality of life.
Establishing what would constitute success prior to starting them sets patient and clinician expectations.
Deprescribing appropriately
It is important to encourage patients to consider whether their medications are working and the extent to which side effects may be having an impact on their lives. Side-effects may be insidious and patients may consider them to be part of the presentation of their pain or other conditions. Any decision about deprescribing should be made with the patient, especially where there is likely to be dependence or withdrawal (NICE, 2022).
If medications are not providing significant relief, then weaning (slowly and with patient input) will reduce the risk of long-term effects and side effects. If medications are not effective, it is best to wean even in the absence of any other analgesia options. Conversely, if the patient wants to continue taking medications that they feel are effective (at a safe dose), this should be respected. This applies even where the NICE guidelines for chronic primary pain identifies the medication as inappropriate (NICE, 2021a).
Engaging early with specialist services
Specialist pain management services provide holistic assessment and management strategies for patients with chronic pain. Although they do offer advice about pharmacological management, this forms only a small part of the input, which aims to improve quality of life and foster self-efficacy and self-management.
‘Shared decision making can help to set expectations and foster a sense of shared responsibility that is beneficial to the therapeutic relationship’
Engaging with these services can help to set patients up well with optimal analgesia and develop a tool-kit of self-management strategies. Early referral is encouraged.
Conclusion
Prescribing for chronic pain can be challenging, and unrealistic expectations of the efficacy of analgesia for chronic pain can be a source of frustration for patients and clinicians alike. Shared decision making can help to set expectations and foster a sense of shared responsibility beneficial to the therapeutic relationship.
Once the decision to prescribe has been made, agreeing criteria for success or discontinuation of medication with patients ensures that patients do not continue to take medications where risks outweigh benefits. Specialist pain management services are available to support the long-term management of patients with chronic pain.