Pain Concern’s response to NHS England’s proposal to restrict prescribing of certain pain medicines by general practitioners

Pain Concern is a national charity that supports those who live with long term pain, and those who care for them, by providing information on pain and its management through a variety of media platforms. We also raise awareness about pain and the need to improve the provision of pain management services through campaigning and research.

We wish to express our concerns regarding NHS England’s proposal to restrict prescribing of certain pain medicines by general practitioners. Analysis of information from our online forum and helpline, supports national and regional audits and surveys (National Pain Audit, The Painful Truth), and confirms that many, but by no means all, who live with long term pain derive benefit from their pain medicines enabling them to have a more active and productive life and reducing the burden on healthcare services .

We recognise that long term pain is more prevalent in older people, often with co-morbidities, who are at greater risk of drug interactions and falls when taking certain analgesic and sedative medicines.

We are also aware that there is regional variation in the provision of secondary care pain clinics and fear that prescribing restrictions on General Practitioners and Independent Prescribers may create additional pressures on these services; they will require additional resources to meet demand.

Our specific comments are as follows:

• 8% lidocaine plasters. In the treatment of localised neuropathic pain, for example post-herpetic neuralgia. These appear to offer a safer alternative to tricyclic or other antidepressants, anti epileptic drugs, and gabapentin/pregabalin, particularly in older adults, the demographic most vulnerable to neuropathic pain. A proportion of such patients have tried these oral medicines and found them to be ineffective or to have intolerable side effects, and have found relief from lidocaine plasters. Skin reactions appear to be rare, although failure of adhesion can be troublesome.
• Oxycodone and Naloxone Combination, Targinact. A proportion of people who have been unable to control their constipation when taking oral morphine, oxycodone or other strong opioid with laxatives (often in combination) report a significant improvement when changed to Targinact. If this medicine were not available to them we would wish to see Clinical Commissioning Groups make Naloxegol prescribed in conjunction with oxycodone.
• Co-Proximol. We recognise the risk of respiratory depression in overdose and the limited benefit of paracetamol/weak opioid combinations in the management of long term pain, so do not have concerns regarding restrictions to prescribing this medicine.
• Tramadol with paracetamol combination tablet. No concerns if this is to be replaced by prescription of paracetamol and tramaol as separate medicines.
• Dosulepin. Our concern here would be regarding access to this medicine for those who are intolerant of the side effects of older tricyclic antidepressants. We are aware that the dose used in pain management is lower than that for the treatment of depression yet the risk of harm has been studied in those receiving treatment for depression. We would caution against extrapolation of this data to the lower dose.
• Trimipramine. Again it is important to remember that this drug is used for pain management at doses much lower than for depression and yet the risk data related to its use at higher dose.
• Immediate Release Fentanyl. While recognising the value of this medicine in the control of breakthrough pain in end-of-life care, we have concerns regarding the use of immediate release strong opioids in the context of long term pain and do not promote their use. We have no concerns regarding restrictions to its prescription in primary care in this context.
• Over the counter medicines. There is a strong association between poverty and long term pain. One quarter of those who live with long term pain will lose their jobs because of this. Despite a lack of scientific evidence for their use as sole agents in the management of long term pain, many rely on simple analgesics (paracetamol/codeine/non-steroidal anti-inflammatory drugs) to augment the benefit of stronger analgesics or to minimise their dosage. Paying for OTC medicines places another financial  burden on such people.

Long term pain degrades physical and mental health, and is a significant burden on the sufferer, their families, society and  health and care services. Many people report that it has taken years to find that combination of medicines, physiotherapy and psychological support that allows them a better quality of life, and we would not wish to see access to beneficial medicines restricted. We applaud NICE in its efforts to provide a framework for appropriate prescribing in long term pain and its recognition that this needs be tailored to the specific needs of the individual patient., and hope that NHS England will take a similar view.