Is Chronic Pain Guidance Delivering What NICE Promised?

A few years ago, when pain specialist Blair Smith was working at NHS Tayside’s Pain Service, he and colleagues received an influx of referrals from GPs asking them to take over the management of some patients. The GPs had — because of new guidelines from the National Institute for Health and Care Excellence (NICE) — stopped prescribing painkillers to manage chronic primary pain and their patients needed help.“We got referrals from GPs telling us they had stopped prescribing say, tramadol, because of the guidelines and could we please take over management,” Professor Blair Smith, chair of Population Health Science at the University of Dundee and academic GP, told Medscape News UK.Blair Smith“It was incredibly frustrating because the patients had been doing ok on their medicines and came to us in distress because their GP had stopped the prescription. And this is in Scotland [despite SIGN being the formal standard] – I’m sure the situation was way worse in England and Wales. The pain service is under increasing, intense pressure and this was just an unnecessary pressure on our ability to provide the services we needed to provide.” In 2021, NICE published guidelines on assessing all chronic pain (chronic primary pain, chronic secondary pain, or both) and managing chronic primary pain in people over 16. The guidelines told GPs to stop prescribing painkillers, including paracetamol, NSAIDs, and antiepileptic drugs, and instead recommended exercise programs and physical activity, psychological therapy — specifically, acceptance and commitment therapy (ACT) and cognitive behavioural therapy — acupuncture, and antidepressants, when treating pain with no clear underlying cause, or pain which is out of proportion to any observable injury or disease.Scotland, however, does not follow NICE guidance. At the time of Smith’s referrals, prescribing in Scotland was governed by SIGN 136, the Scottish Intercollegiate Guidelines Network’s chronic pain standard — which, unlike NICE, allowed opioids to be considered on a short-to-medium-term basis. That NICE’s guidance appeared to be shaping practice there regardless caught Smith by surprise. SIGN has since updated its guidance — SIGN 173, published in 2025. Like NICE, it advises against opioids being prescribed routinely, but says they can be considered for carefully selected patients on a short-term basis (up to 3 months) once other pain therapies have been tried — and that people already on long-term opioids should have their prescriptions reviewed, with a view to reducing or stopping treatment where the harms outweigh the benefit. As with NICE, it points to realistic goal setting with patients, early support for self-management, and non-drug approaches as central to care. In March 2026, the Scottish Government issued a further prescribing guide of its own.For Smith, the new guidelines weren’t only confusing, but they were genuinely controversial. Others agreed. At the time, the British Pain Society said the “inexpert withdrawal of medication in such a vulnerable group of patients could easily lead to despair and unintended harm”, while the Faculty of Pain Medicine of the Royal College of Anaesthetists expressed concern about the recommendation of treatments such as acupuncture which would “suggest that the majority of primary pain is likely to be musculoskeletal”, that could likely also “foster passivity of management by sufferers of chronic pain.”“I wasn’t impressed, partly because of what NICE said and how they said it, but for the impact it would have on people who were living with pain and the changes it would force people to make who were managing them,” Smith said. Smith explained that the use of the term “chronic primary pain” was unfortunate because NICE had, at the time, invented a new term that was yet to exist. “They invented this new term and then went searching for trials that supported evidence for the treatment of chronic primary pain, but there were no trials because the term didn’t exist. However, there were lots and lots of trials for conditions which would later come under the banner of chronic primary pain, but they haven’t been taken into consideration.” At the time, Smith was working with the World Health Organization (WHO) to define chronic primary pain, which was defined by WHO when the International Classification of Diseases 11th Revision (ICD-11) was approved, and later came into effect in 2022. It is defined as pain lasting or recurring for more than 3 months, tied to emotional distress or functional disability, and not better explained by another condition. This group of pain disorders includes fibromyalgia, complex regional pain syndrome, chronic primary headache, and orofacial pain, as well as visceral pain and musculoskeletal pain, including chronic primary low back pain. However, as experts stressed, each of these distinct conditions require individual approaches to treatment, rather than a blanket one-size-fits-all approach to the guidelines.So, 5 years on, are patients with chronic primary pain receiving the type of interventions NICE envisioned? And how can GPs help patients with chronic primary pain? The Access Problem Professor of medical psychology and pain science and director of the Centre for Pain Research at the University of Bath, Christopher Eccleston, PhD, told Medscape News UK that he wouldn’t want to be a GP managing pain patients. “I wouldn’t want to be a GP, because you haven’t got very much to do. We tend to think that 20% of the population have pain, but 20% of them have severe, treatment-resistant, high-impact pain. That’s 3 million people in the UK,” he said. “Arguing whether you should do this type of therapy or that type of therapy sometimes, to me, seems a bit unnecessary, because there’s a vanishingly small number of people who are going to get access to these things. Maybe instead we should be putting all our efforts into scalable, accessible digital methods.” The accessibility of acupuncture, for example, through the NHS is unclear. While it is free, availability is extremely limited and usually restricted to pain clinics and physiotherapists. Meanwhile, NHS psychological care waiting lists are severely strained, with an estimated 1.7 million people waiting for mental health treatment in the UK. This leaves patients with two options: pay out-of-pocket to see a private professional sooner or wait until an appointment becomes available. Eccleston told Medscape News UK that with only 150 pain clinics across the UK, and a limited number of qualified people able to deliver interventions, the unmet need is huge and geographically uneven. That, he said, begs the question: what can be taken from specialist tertiary pain services that we know work, and adapted for primary care?In his view, applying a broad biopsychosocial framework lets primary care providers create an empathetic environment to talk about pain, validate patients’ experience, and introduce new ways of coping — together shifting the trajectory towards effective self-management.“I’m of the view that we should share skills as widely as we possibly can. If we focus on validating the patient’s experience and try to assess core beliefs around what needs to be done and promote self-management really on, I think we might be able to change the trajectory,” he said. “But there is probably a threshold by which you’re just having a chat with somebody rather than affecting any change – but we don’t really know what that threshold is. But in the meantime, let’s see what we can do.” The Power of Validation Professor of Health Psychology, Tamar Pincus, PhD, Dean of the Faculty of Environmental and Life Sciences at the University of Southampton, whose research focuses on the psychological aspects of chronic pain, researches some big questions – and the answers could very well guide primary health care towards better pain management. Among these: Why do some people get stuck in persistent pain? What drives it? How can we intervene to change this? What can clinicians do differently to empower the patient?One of the most powerful yet simple interventions, according to Pincus, is validation.“Keep in mind that for most of the patient’s life, the clinician isn’t there – all they can do is nudge. But in that consultation, they can change things sufficiently in the patient to change their self-efficacy, mood, and the ways in which they monitor their body – they can shift them into the mindset of ‘I am not in pain; there is more to me than pain’,” she said.“A simple validation such as saying, ‘I hear you, I understand you, I believe you and you’re not mad’, is a powerful intervention. It’s really quick. We have to start by listening to the patient and asking them: ‘What do I need to know?’ Is it enough? Probably not, but sometimes yes.”For Pincus, continuity of care is a vital part of validation. “It’s so hard on GPs. There’s not one treatment that is effective for everyone. There are people who really respond to paracetamol and others who respond to acupuncture,” she said.“GPs need a chance to try things with people – and continuity of care is vital for this. The vast majority of GPs went into the job wanting nothing more than to get to know their patients, but it’s driven out of them because of the system. One thing we’re learning is that individualised care is way more effective than centralised care.”What Comes Next Eccleston sees huge potential in digital interventions for chronic pain management, particularly for the delivery of different types of therapies, such as ACT. “A lot of what can be delivered is through conversations, through words, and that can be an app. One of the big questions in this field is: how much can you automate? And can you automate it in a way that it will be acceptable to people?“We can build an approach to try and shift a patient’s identity towards self-determination and what they can do to build strength and new coping mechanisms and how to reduce the distress, disability, and depression. We can build people back into a position where they’re able to cope with persistent pain.” Smith believes digital interventions could play a role in the future, but not for everyone. What he believes would have the greatest impact on better pain management now is a reframing and re-understanding of what it looks like to live with chronic pain.“I think there are often mismatched expectations. If healthcare professionals, particularly in primary care, and patients, had a better understanding of what chronic pain is and what is important in its management, I think managing it would be a lot easier and more successful,” he said.“If there’s understanding that chronic pain is a condition for which there is generally no cure, and right from the start the expectation was to optimizs how well someone lives with chronic pain, I think we’d get a lot further, a lot quicker, and a lot more safely.” Eccleston holds grant funding via the University of Bath for research from Arthritis UK, the Medical Research Council, The Economic and Social Research Council, and the MayDay Fund. In the last 3 years he has consulted personally for Newell Health, Orion Pharma, and Reckitt. Sophie Cousins, MIPH, is a global health journalist who has reported from more than 20 countries.