Re: Chronic pain - New NICE Guideline Summary: Antidepressants and chronic pain - chicken or egg?
Dear Editor
Chronic pain is debilitating and depressing. The new NICE guideline says “Chronic primary pain has no clear underlying condition or the pain (or its impact) appears to be out of proportion to any observable injury or disease” (1). This description or definition of chronic pain is deeply troubling, especially when taken together with the Guideline’s confident recommendation under “management” for pharmacological treatment with antidepressants, “even in the absence of depression”.
We are hearing from many people who have developed ‘unexplained’ chronic pain conditions after taking antidepressants, as prescribed on- or off-label, and sometimes over many years – and this has often led on to polypharmacy with other drugs added ‘for symptoms’ along the way, most likely including benzodiazepines, z-drugs, opioids and/or gabapentinoids. These are the five classes of drugs that were included in the PHE Review of “Dependence and Withdrawal associated with some prescribed medicines” which reported in September 2019 (2). Of course, all of these drugs add more layers of dependency and other side-effects and adverse-effects – as well as (now slightly better recognised) complex withdrawal problems.
Building on the work of others, who had already been raising concerns over many years, we have ourselves been campaigning about the issues of adverse effects of commonly prescribed antidepressants (especially) and benzodiazepines since 2014, as summarised in our BMJ response April 2018 “Is the BMJ - and the medical profession that it represents - really listening to patients and the public?” (3).
Following this, our own systemic research with the All Party Parliamentary Group for Prescribed Drug Dependence, drawing on the detailed written evidence submitted for our 2017 Scottish and Welsh Public Petitions (4), was analysed (together with further patient experience evidence) within the National Guideline Centre 2019 “Patient experience: review of evidence” publication (5) and was included in section 4 on “Patient experiences of harms” in the PHE Review Report 2019 (2).
In 2020 an expanded version of our work was published by Therapeutic Advances in Psychopharmacology (6), with a specific focus on how antidepressant effects and withdrawal effects are frequently missed or misdiagnosed, and this aspect has been further explored in our article for The Journal of Critical Psychology, Counselling and Psychotherapy “The Patient Voice: Antidepressant Withdrawal, Medically Unexplained Symptoms, and Functional Neurological Disorders” (7).
In this context, we were stunned to read the statement on 7 April 2021 by NICE (1) that “The antidepressants amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine, or sertraline are the only drug treatments that should be offered to patients with chronic primary pain because evidence shows these may improve quality of life, pain, sleep, and psychological distress, even in the absence of depression” and that “For many commonly prescribed drugs, including paracetamol, non-steroidal anti-inflammatory drugs, benzodiazepines, or opioids there is little or no evidence that they make any difference to people’s quality of life, pain, or psychological distress, but they can cause harm, including possible addiction.”
So … what the new NICE guideline apparently suggests is that people will be called for review of their medications and recommended to be withdrawn from the ‘addictive’ medicines – and that ‘non-addictive’ antidepressants will be the only pharmacological option ‘recommended’. This scenario is fraught with problems. Deprescribing of polypharmacy is complex – and in any case the same people will very likely already be taking prescribed antidepressants, and already be suffering from various adverse effects of these … which (effects) may indeed have led on to the chronic pain conditions which resulted in polypharmacy.
There have been many concerns raised about antidepressants, which (concerns) seem in this new primary chronic pain guidance (1) to be completely overlooked by NICE, once again. Could it be that the antidepressants are the problem, as detailed by John Warren 2020 “The trouble with antidepressants: why the evidence overplays benefits and unplays risks”? (8).
The Cochrane Collaboration evidence on “Approaches for discontinuation versus continuation of long-term antidepressant use…”, just published (9), confirms beyond doubt the very issues around the longer-term safety of antidepressants that we have been flagging ourselves - and especially the problems which arise around ‘discontinuation’. In many cases of chronic pain, antidepressants may actually have been the ‘gateway’ drug.
Herald Scotland has now reported this Cochrane review within the current (April 2021) Scottish context. This makes for alarming reading, certainly rising important questions about antidepressants - and chronic pain - chicken or egg? (10). This Herald report includes information about the Scottish Government Short Life Working Group’s online Public Consultation on ‘prescription medicine dependence and withdrawal’, currently open for public input until 4 June 2021 (11).
(1) Chronic pain (primary and secondary) in over 16s: summary of NICE guidance. BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n895 (Published 21 April 2021)
(2) Taylor S, Annand F, Burkinshaw P, Greaves F, Kelleher M, Knight J, Perkins C, Tran A, White M, Marsden J. Dependence and withdrawal associated with some prescribed medicines: an evidence review. Public Health England, London. 2019. Dependence and withdrawal associated with some prescribed medicines: an evidence review (publishing.service.gov.uk)
(3) Brown M et al. BMJ rapid Response April 2018 Is the BMJ – and the medical profession that it represents – really ‘listening to patients’ and the public? | The BMJ
(4) Guy A, Brown M, Lewis S, Reid S, Espley K, Cope D, et al. The Patient Voice: an analysis of personal accounts of prescribed drug dependence and withdrawal submitted to petitions in Scotland and Wales. : All Party Parliamentary Group for Prescribed Drug Dependence; 2018 Voice-of-the-Patient-Petition-Analysis-Report-for-publication-081018.pdf (prescribeddrug.org)
(5) National Guideline Centre. RCP: Carville, S, Ashmore, K, Cuyàs, A, et al Patients’ experience: review of the evidence on dependence, short term discontinuation and longer term withdrawal symptoms associated with prescribed medicines 2019. https://www.rcplondon.ac.uk/file/13705/download?token=F3JJ3PKJ.
(6) Guy A, Brown M, Lewis S, Horowitz M. The ‘patient voice’: patients who experience antidepressant withdrawal symptoms are often dismissed, or misdiagnosed with relapse, or a new medical condition. Therapeutic Advances in Psychopharmacology. January 2020. doi:10.1177/2045125320967183
(7) Brown, M. Lewis, S. (2021). The Patient Voice: Antidepressant Withdrawal, Medically Unexplained Symptoms, and Functional Neurological Disorders. Journal of Critical Psychology, Counselling, and Psychotherapy, 20 (4), 14-20 (1) (PDF) JCPCP v20 i04 Brown&Lewis (researchgate.net) Contents - JCPCP, Vol. 20, No. 4, Winter 2020 (egalitarianpublishing.com)
(8) Warren J B. The trouble with antidepressants: why the evidence overplays benefits and underplays risks. BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3200
(9) Van Leeuwen E, Driel ML, Horowitz MA, Kendrick T, Donald M, De Sutter AIM, Robertson L, Christiaens T. Approaches for discontinuation versus continuation of long‐term antidepressant use for depressive and anxiety disorders in adults. Cochrane Database of Systematic Reviews 2021, Issue 4. Art. No.: CD013495. DOI: 10.1002/14651858.CD013495.pub2. Accessed 24 April 2021.
(10) McArdle H, ‘No good evidence’ for long-term use of antidepressants. Herald Scotland 25 April 2021 'No good evidence' for long-term use of antidepressants | HeraldScotland
(11) Short Life Working Group on Prescription Medicine Dependence and Withdrawal - Consultation on Draft Recommendations - Scottish Government - Citizen Space
Rapid Response:
Re: Chronic pain - New NICE Guideline Summary: Antidepressants and chronic pain - chicken or egg?
Dear Editor
Chronic pain is debilitating and depressing. The new NICE guideline says “Chronic primary pain has no clear underlying condition or the pain (or its impact) appears to be out of proportion to any observable injury or disease” (1). This description or definition of chronic pain is deeply troubling, especially when taken together with the Guideline’s confident recommendation under “management” for pharmacological treatment with antidepressants, “even in the absence of depression”.
We are hearing from many people who have developed ‘unexplained’ chronic pain conditions after taking antidepressants, as prescribed on- or off-label, and sometimes over many years – and this has often led on to polypharmacy with other drugs added ‘for symptoms’ along the way, most likely including benzodiazepines, z-drugs, opioids and/or gabapentinoids. These are the five classes of drugs that were included in the PHE Review of “Dependence and Withdrawal associated with some prescribed medicines” which reported in September 2019 (2). Of course, all of these drugs add more layers of dependency and other side-effects and adverse-effects – as well as (now slightly better recognised) complex withdrawal problems.
Building on the work of others, who had already been raising concerns over many years, we have ourselves been campaigning about the issues of adverse effects of commonly prescribed antidepressants (especially) and benzodiazepines since 2014, as summarised in our BMJ response April 2018 “Is the BMJ - and the medical profession that it represents - really listening to patients and the public?” (3).
Following this, our own systemic research with the All Party Parliamentary Group for Prescribed Drug Dependence, drawing on the detailed written evidence submitted for our 2017 Scottish and Welsh Public Petitions (4), was analysed (together with further patient experience evidence) within the National Guideline Centre 2019 “Patient experience: review of evidence” publication (5) and was included in section 4 on “Patient experiences of harms” in the PHE Review Report 2019 (2).
In 2020 an expanded version of our work was published by Therapeutic Advances in Psychopharmacology (6), with a specific focus on how antidepressant effects and withdrawal effects are frequently missed or misdiagnosed, and this aspect has been further explored in our article for The Journal of Critical Psychology, Counselling and Psychotherapy “The Patient Voice: Antidepressant Withdrawal, Medically Unexplained Symptoms, and Functional Neurological Disorders” (7).
In this context, we were stunned to read the statement on 7 April 2021 by NICE (1) that “The antidepressants amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine, or sertraline are the only drug treatments that should be offered to patients with chronic primary pain because evidence shows these may improve quality of life, pain, sleep, and psychological distress, even in the absence of depression” and that “For many commonly prescribed drugs, including paracetamol, non-steroidal anti-inflammatory drugs, benzodiazepines, or opioids there is little or no evidence that they make any difference to people’s quality of life, pain, or psychological distress, but they can cause harm, including possible addiction.”
So … what the new NICE guideline apparently suggests is that people will be called for review of their medications and recommended to be withdrawn from the ‘addictive’ medicines – and that ‘non-addictive’ antidepressants will be the only pharmacological option ‘recommended’. This scenario is fraught with problems. Deprescribing of polypharmacy is complex – and in any case the same people will very likely already be taking prescribed antidepressants, and already be suffering from various adverse effects of these … which (effects) may indeed have led on to the chronic pain conditions which resulted in polypharmacy.
There have been many concerns raised about antidepressants, which (concerns) seem in this new primary chronic pain guidance (1) to be completely overlooked by NICE, once again. Could it be that the antidepressants are the problem, as detailed by John Warren 2020 “The trouble with antidepressants: why the evidence overplays benefits and unplays risks”? (8).
The Cochrane Collaboration evidence on “Approaches for discontinuation versus continuation of long-term antidepressant use…”, just published (9), confirms beyond doubt the very issues around the longer-term safety of antidepressants that we have been flagging ourselves - and especially the problems which arise around ‘discontinuation’. In many cases of chronic pain, antidepressants may actually have been the ‘gateway’ drug.
Herald Scotland has now reported this Cochrane review within the current (April 2021) Scottish context. This makes for alarming reading, certainly rising important questions about antidepressants - and chronic pain - chicken or egg? (10). This Herald report includes information about the Scottish Government Short Life Working Group’s online Public Consultation on ‘prescription medicine dependence and withdrawal’, currently open for public input until 4 June 2021 (11).
(1) Chronic pain (primary and secondary) in over 16s: summary of NICE guidance. BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n895 (Published 21 April 2021)
(2) Taylor S, Annand F, Burkinshaw P, Greaves F, Kelleher M, Knight J, Perkins C, Tran A, White M, Marsden J. Dependence and withdrawal associated with some prescribed medicines: an evidence review. Public Health England, London. 2019. Dependence and withdrawal associated with some prescribed medicines: an evidence review (publishing.service.gov.uk)
(3) Brown M et al. BMJ rapid Response April 2018 Is the BMJ – and the medical profession that it represents – really ‘listening to patients’ and the public? | The BMJ
(4) Guy A, Brown M, Lewis S, Reid S, Espley K, Cope D, et al. The Patient Voice: an analysis of personal accounts of prescribed drug dependence and withdrawal submitted to petitions in Scotland and Wales. : All Party Parliamentary Group for Prescribed Drug Dependence; 2018 Voice-of-the-Patient-Petition-Analysis-Report-for-publication-081018.pdf (prescribeddrug.org)
(5) National Guideline Centre. RCP: Carville, S, Ashmore, K, Cuyàs, A, et al Patients’ experience: review of the evidence on dependence, short term discontinuation and longer term withdrawal symptoms associated with prescribed medicines 2019. https://www.rcplondon.ac.uk/file/13705/download?token=F3JJ3PKJ.
(6) Guy A, Brown M, Lewis S, Horowitz M. The ‘patient voice’: patients who experience antidepressant withdrawal symptoms are often dismissed, or misdiagnosed with relapse, or a new medical condition. Therapeutic Advances in Psychopharmacology. January 2020. doi:10.1177/2045125320967183
(7) Brown, M. Lewis, S. (2021). The Patient Voice: Antidepressant Withdrawal, Medically Unexplained Symptoms, and Functional Neurological Disorders. Journal of Critical Psychology, Counselling, and Psychotherapy, 20 (4), 14-20 (1) (PDF) JCPCP v20 i04 Brown&Lewis (researchgate.net) Contents - JCPCP, Vol. 20, No. 4, Winter 2020 (egalitarianpublishing.com)
(8) Warren J B. The trouble with antidepressants: why the evidence overplays benefits and underplays risks. BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3200
(9) Van Leeuwen E, Driel ML, Horowitz MA, Kendrick T, Donald M, De Sutter AIM, Robertson L, Christiaens T. Approaches for discontinuation versus continuation of long‐term antidepressant use for depressive and anxiety disorders in adults. Cochrane Database of Systematic Reviews 2021, Issue 4. Art. No.: CD013495. DOI: 10.1002/14651858.CD013495.pub2. Accessed 24 April 2021.
(10) McArdle H, ‘No good evidence’ for long-term use of antidepressants. Herald Scotland 25 April 2021 'No good evidence' for long-term use of antidepressants | HeraldScotland
(11) Short Life Working Group on Prescription Medicine Dependence and Withdrawal - Consultation on Draft Recommendations - Scottish Government - Citizen Space
Competing interests: No competing interests