What's the best way to manage chronic pain? Nice say it's exercise.

Tori_Scope · April 2021

The National Institute for Health and Care Excellence (Nice) released new guidelines on chronic pain on Wednesday, recommending sufferers of chronic primary pain – pain for which there is no clear explanation, such as arthritis or nerve damage – take exercise instead of painkillers.

The logic here seems clear. We know that some pain-relieving drugs such as opioids and gabapentinoids don’t work that well for chronic pain, but are perversely associated with higher rates of addiction and the chance of overdosing and dying. This risk seems to be highest in those who are anxious or depressed, the same individuals who are least resilient to pain. Instead, for such central pain processes, Nice suggests treatment with antidepressants, talking therapies, exercise and acupuncture.

Yet despite Nice’s good intentions, I fear a foreseeable consequence of this new guidance will be the increased suffering of chronic pain patients with the indiscriminate withdrawal of powerful analgesics from many chronic pain patients by NHS commissioners.

Pain is not one thing but a complex phenomenon of many causes and processes. There are those that we can “see” – such as arthritis, soft tissue and nerve damage. We also know that the invisible processes of the mind profoundly determine our pain experience. Yet pain is not a diagnosis, rather a symptom that may represent many different pathologies. I find it difficult to accept the Nice guidelines, which categorically state, “Do not offer this or that treatment.” None of us as doctors or scientists can say that. Each patient is unique and their pain is unique.

Unfortunately, all the conventional medical drugs we use for pain can cause side-effects. Opioids such as morphine, as well as causing constipation and cognitive problems, have been shown to cause a long-term decrease in quality of life in those who take the drugs regularly, with onset of cravings and addiction.

But many chronic pain patients rely on such drugs to achieve any quality of life. I know chronic pain is torture, dominating every moment of the day. People like me will at times need powerful drugs, sometimes morphine and gabapentin, to control arthritic joint pain, nerve pain, or more widespread pain and associated anxiety and depression.

Patients in pain are not one thing. We doctors need to be compassionate and carefully talk to our patients and assess the various complexities of their pain, as it is unpredictable what will work. We need to remember our shared humanity and suffering with our patients, for it could be any one of us sitting opposite the pain doctor in the clinic room.

What do you think? How could doctors be more compassionate towards patients living with chronic pain? How do you manage your chronic pain?

chiarieds · April 2021

Hmmm... this is perhaps a case of poor journalism. The NICE guidelines are about chronic primary pain, i.e. that for which there is no known cause, whereas secondary chronic pain is identified as in those patients that have an underlying cause such as 'arthritis,' which is a poor definition, but usually denotes osteoarthrosis, or rheumatoid arthritis. Neuropathic pain is also mentioned as being of the secondary type of chronic pain. So, this article is misleading; NICE's gudelines are solely about pain of an unknown cause, & why some strong medications such as opiods, gabapentin or pregabilin should not be considered.

However, falling into the category of someone who has secondary chronic pain due to generalised osteoarthrosis + neuropathic pain, there is also a consensus that drugs like opiods can help, but only in the short term. Personally I gradually came off the opiods (fentanyl patches) my GP had prescribed, & felt no worse. I have tried coming off Gabapentin 3 times, but realise it does indeed dampen down my neuropathic pain somewhat.

With my physio background, I also appreciate how much exercise helps, & exercise several times a day. I would say that any exercise is better than none, & should be beneficial. With secondary chronic pain there are also other avenues to explore. I mainly use exercise, but also distraction. I also take cannabidiol, & within 3 weeks of starting this found my lower back pain was helped (something I hadn't even considered, as it was my least concern)... a little later I realised that the partial joint dislocations I normally had, had reduced. I had actually hoped it would help my neuropathic pain, but unfortunately not.

Sandy_123 · April 2021

Hmm i disagree and agree on this. Talking personally with my own pain, I found i have to keep my back active on good days to reduce the flare ups and pain further down the line, for instance
When I was working and had a couple of days off my back was worse when I went back to work because I didn't get same exercise on rest days, if that makes sense,
When I flare up and get bad pain on bad days, then I go to painkills, antinflamatries, I agree the side effects on strong pain relief limits me as it makes me drowsy and sleep.
There is something about exercise and keeping well. But to one's limitations. I don't agree that Dr's shouldn't prescribe painkillers as nothing worse then pain.

Pixie51 · May 2021

After a few years of chronic pain and being diagnosed with fibro ( I have opinions regarding this but that's another story!) the lovely consultant spent a lot of time with me talking over the benefits of exercise. I was very overweight and in a lot of pain and in my head I was laughing ironically at the thought of me doing much exercise, despite having been pretty sporty previously. But, he said try yoga it's not what you perceive it to be. So I found an amazing tutor who incidentally has ME and I was stunned by her ability to stretch and yet have chronic pain. She told me that the stretching helped the pain and literally one class had me hooked. I went on to train as an instructor and now mainly work with people struggling with self image and chronic pain. I guess what I am saying is, exercise is good. I understand not everyone can exercise in the conventional sense of the word. But a little yogic breathing if possible and stretching what can be stretched helps release tension, potentially lowers blood pressure which is good for your heart and reduces stress and anxiety. It really can help. People listen to me and assume that as I am a yoga instructor that I cannot have chronic pain, but the reason my pain is a little more under control is because I practice yoga.

What's the best way to manage chronic pain? Nice say it's exercise.

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