Nurses and other health professionals may find chronic pain complex and challenging to manage. Those experiencing chronic pain often expect a definitive diagnosis and effective treatment but this may not always be possible. Appropriate assessment, cautious drug choice and alternatives can improve the experience and outcomes of care for people with chronic pain. The first step in developing an effective care and support plan requires the nurse to have an understanding of how pain affects a person's life and those around them—their work and leisure time, their relationships with family and friends, rest and sleep, and quality of life. Each person with chronic pain will experience their pain differently and a one-size-fits-all approach is not acceptable. Providing people with more options to help them manage their pain effectively demonstrates a commitment to individualised care. The National Institute for Health and Care Excellence (NICE) has produced guidance for assessment and development of a care and support plan with a focus on treatments for chronic primary pain (NICE, 2021). It does not cover pain management as part of palliative care.
There is little or no evidence that, for people with chronic primary pain, commonly used drugs such as paracetamol, non-steroidal anti-inflammatories, benzodiazepines or opioids make any difference to the person's quality of life, pain or psychological distress. The guideline makes proposals for treatment options shown to be effective in managing chronic primary pain. Treatment modalities may include exercise programmes and psychological therapies such as cognitive behavioural therapies (CBT) and acceptance and commitment therapy (ACT). Acupuncture is also suggested as an option.
Implementation of these guidelines may cause consternation for patients and nurses, by asking people to stop taking their medicines without offering safer and more effective alternatives. The guideline advises people who are taking medicines for their chronic primary pain that are not recommended to seek advice for a review of their prescribing as part of shared decision making. Agreeing a plan to carry on taking their medicines if they are providing benefit at a safe dose with little harm or to offer support to reduce and stop the medicine if possible, is suggested.
The recommendations reflect best practice and many are currently implemented in a number of ways across NHS settings, but full implementation will involve a change of practice for a number of care providers. There will need to be provision for longer consultations and additional follow up to discuss self-management and treatment options. There is wide variation across the UK in the availability and use of the various treatment options, and there are likely to be resource impacts. The recommendation is expected to lead to a rise in the demand for acupuncture services—acupuncture provided as an individual patient intervention is very staff intensive, and there has been a recent reduction in these services (NICE, 2021). Exercise programmes offered vary across the country and are usually decided by the needs of the local population—supervised group exercise may not be offered. The guideline development committee is suggesting that if costs are incurred by engaging in physical activity after a formal exercise programme ends, this would be a personal cost for the patient and the cost would not fall to the NHS (NICE, 2021). Although CBT is used in the NHS for chronic primary pain, this is not standard practice everywhere and ACT is a relatively new intervention also subject to variation in practice. The costs for these interventions are contingent on the number and length of sessions, whether they are group or individual (or face to face or virtual) and who is running them.
It is the responsibility of local commissioners and providers of health care to enable the guideline to be applied. It is therefore the responsibility of commissioners and providers to ensure that nurses are adequately supported in its implementation.