New draft NICE guidelines for chronic pain emphasises exercise, CBT and acupuncture over medication

NICE have issued a clarification in response to the Countess of Mar's enquiry:

https://meassociation.org.uk/2020/0...-get-covid-19-and-new-guideline-chronic-pain/

 

Re medication for pain. I've found that only after two doses of my pain med duo (low dose of methadone and half a tizanidine--muscle relaxant) which is at the end the day, can I do any stretches whatsoever.

My muscles seem to be in spasm without these drugs, or at least they feel that way, as though stretching would rip them. They just don't 'stretch.'

So meds first, then if someone wants to try out acupuncture and assorted woo-doo, fine, I don't care (not for me, I've tried all).

Relieve pain or some of it first. There is no getting away from that.

 

Interestingly enough, Jo Daniels Twitter account seems to have been suspended.

Edit : Turns out that the Twitter account has been restricted by Daniels herself such that tweets can only be read by members "approved" by her.

When I click on the above link I get told the account has been suspended. I'm not a member of Twitter.

 

It was not exactly smart to make a public statement of opinion while being subject to restrictions on such statements because of her (unwelcome and superfluous) involvement on the NICE committee. Oh well.

Then again she initially expressed this opinion and nothing happened so I guess one more oversight can be expected. Things have heated up a bit on that front, the issue will be far more visible than anyone had expected going on.

 

The Guardian: Chronic pain sufferers should take exercise, not analgesics, says Nice

Quote:
Nice recommends that doctors draw up a care and support plan with patients about how to manage their pain based on how badly it is affecting their day-to-day life, what activities they feel they can undertake and honesty “about the uncertainty of the prognosis”.

The plan should include “interventions that have been shown to be effective in managing chronic primary pain. These include exercise programmes and the psychological treatments cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT).

“Acupuncture is also recommended as an option, provided it is delivered within certain clearly defined parameters,” Nice says.

The antidepressants amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline can also be used, it adds.

 

So hospitals have been using interventions which, by implication, have not been shown to be effective against pain when dealing with people involved in accidents which have caused major trauma?

When will we see paramedics treating burn victims with CBT?

Or A&E intensive care staff treating people with missing limbs with exercise, and nothing else?

Oh no....if you're in pain the one thing that you can't have is pain killers that work.

Is this some form of religion?

No, it's medicine (or what they aim to turn medicine into).

What is medicine for if not to treat pain, of all types - hopefully to keep people who wish to be alive alive, and as functional as possible, but treating pain, that's a biggie, probably one of the biggest reasons for medicine to exist, after the whole try and stopping people from dying inconveniently thing.

...and now they don't want to.

 

I had thought that the feedback they got from lots of people would have changed their draft. There was such a fight back against it. But It looks like the draft got published in the end without major changes?

 

So is this the finalised version that will go into use? Or just another draft? Because I'm sure I'd read about "no painkillers for pain" before, so I'm confused.

Women are going to suffer more from this than men. And I'm positive the suicide rate will go up. And given that women who are pre-menopausal are likely to be the severely affected by this I imagine the suicide rate will go up in younger women as well as the elderly.

 

Is anyone familiar wit the trial literature for chronic pain? What is the pain equivalent of PACE I wonder?
Pain would seem to pose an even bigger methodological problem since it is subjective all the way.

 

Very very much so.
It is intriguing that paired test treatments always seem to come out exactly the same.
If you try two unvalidated treatments what would be the chances that they would actually be more or less identical in efficacy - close to zero. Yet for PACE and here the test groups show the same effect in comparison to 'usual dross treatment'. It does look suspiciously like a consistent bias effect.
Perhaps the surprising thing is that mindfulness and CBT therapists seem to have exactly the same placebo potential. I would have thought the different coloured cardigans might skew that.

 

And performance bias.

Interventions: CBT (training to change pain-related thoughts and behaviors) and MBSR (training in mindfulness meditation and yoga) were delivered in 8 weekly 2-hour groups. Usual care included whatever care participants received.
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And an intention-to-treat analysis rather than per-protocol despite a non-negligible 15% loss to follow-up.

Results: There were 342 randomized participants, (...) 123 (53.7%) attended 6 or more of the 8 sessions, 294 (86.0%) completed the study at 26 weeks, and 290 (84.8%) completed the study at 52 weeks. In intent-to-treat analyses at 26 weeks [...]
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I'm not sure how this managed to pass JAMA's peer review. Though I'm not sure how the PACE trial managed to pass the Lancet's peer review either.

This should be the take-away message from the study. The consistency between the results for CBT and mindfulness should have more people raising their eyebrows, but instead BPS-oriented pain clinics will cite this as "strong" evidence of the efficacy of the treatments they offer.

 

A UK journalist looking for comments from patients.

 

One problem (of several) I have with this is that I have no idea what group the NHS will conclude I'm in. Do they think I'm suffering from primary or secondary pain? I have an almost life-long history of completely ignored gynaecological problems, that were then discovered during surgery to be severe, after decades of no pain relief. And once the evidence was found these results were then obfuscated and minimised in any kind of summary of my medical records, so that if I tell a doctor what the results actually were they roll their eyes at me, and disbelieve me yet again.

I first developed pain at puberty which just got more and more severe as the years went on. I got my first effective pain relief when I was 55. In the intervening years doctors just appear to have added more and more derogatory labels to my medical records.

The sheer cruelty of this guidance just makes my jaw drop. NICE (or NASTY as I think I might start calling them) are just going all in on this.

I also think this is all political, making the NHS more and more irrelevant to people with chronic pain/illness/disease and it will eventually become just an acute service for accidents and heart attacks, at best. At worst, the service will disappear altogether in practice, so more and more people are forced to go private, if they can afford it, and die, or suffer permanently if they can't.

And what I can't understand is why doctors are not protesting about this. But then their salaries are many times the average, so they can probably afford private medicine anyway. Or at least they can afford good insurance.

 

Here is link to the guideline published today
NICE: Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain

 

The promotion of antidepressants over painkillers says a lot that this is not a problem with the drugs themselves, rather it's the ideological underpinnings of the BPS model that have to be promoted above the very premise of medicine. The harmful consequences of ADs are at least as significant as painkillers, but medicine is in complete denial over this, still blatantly lies about the consequences of ADs in many people.

All proponents of this approach love to trot out that this is for unexplained pain, either oblivious or indifferent to the fact that nearly all chronic pain is unexplained, this is simply not an area that medicine has found any success. The hole in this logic is bigger than the space it occupies. The typical algorithm for temporary pain is to wait for it to go away, it is almost never actually explained.

The pretense that there is any "shared" decision-making in the patient-physician relationship is incredibly dishonest. Patients have exactly as much influence on those decisions as children do about whether they are going to school whether they want it or not. The dishonesty, detached from reality, is incredibly problematic in itself, it shows the complete lack of oversight and self-correction in a process that is fully unidirectional, top-down from people who lack the lived experience to understand the problem, where in fact if they did have this lived experience they would not be able to participate in the process, as being a medical professional is too demanding to be compatible with significant chronic health problems.

Medicine continues its very weird distinction of being the only expert profession that is visibly regressing, eager to bring back old myths that predate modern science and somehow becoming bored with the only process that still to any progress: focused scientific research. It also clearly shows that the biggest knowledge gap in medicine is the complete inability to understand the reality of illness, lived experience cannot be taught to everyone, especially to people trained to dismiss the lived experience of patients, and who never actually know about the outcomes of their work, again because they mostly dismiss what patients report.

 

Interesting to compare this with the ME/CFS draft guideline. For pain there is no documentation of evidence, just some waffle about evidence being positive. Presumably this is a different level of exercise?

I get the clear impression that the pain patient community do not have the sort of advocacy set up that ME/CFS does. The whole thing is a dog's breakfast.