Important benefits and risks of treatment

General

• Numbers needed to treat (NNTs) in the management of chronic pain may appear relatively low, e.g. NNT for gabapentin for managing fibromyalgia is 5.4. However, this means that for every one person with reduced pain intensity, there are four to five people who receive no benefit, with increased risk of adverse effects. Ineffective medication should be safely stopped
• Clinicians should have honest conversations with people at the onset of prescribing about the limitation of medication in the management of chronic pain
• Opioids, gabapentinoids and antidepressants are associated with a risk of dependency^42,43. Individuals should be made aware of these risks on initiation and supported to withdraw these medicines as appropriate
• Clinicians should be aware of the possibility that some individuals may present with ‘drug seeking behaviour’, due to the potential for addiction and withdrawal reactions from gabapentinoids, opioids and antidepressants. MHRA has strengthened advice on the dependency and addiction risk of these medicines
• There are potentially fatal interactions between medicines that cause central nervous system (CNS) depression, particularly opioids, gabapentinoids and benzodiazepines

Medication effectiveness

• Total eradication of pain is unlikely, and evidence reviews frequently consider an intervention effective if it reduces pain by 30%⁵ to 50%⁴⁴
• There is a high placebo effect, highlighting that biopsychosocial effects are contributory factors in pain management. For example, a Cochrane review showed pregabalin 300mg daily reduced pain intensity by 30% in 47% of patients, but the placebo was similarly effective in 42% of patients⁴⁴
• It is important to not only assess the impact of medication on pain levels, but also consider their effect on physical function, mental health and emotional factors (e.g. mood, anxiety, sleep, social and sexual function)