Specialist interventions for managing chronic non-malignant pain in adults

Recommendations for NHSScotland SHTG Council Considerations Evidence Overview Background

The specialist interventions covered by this review are for adults with chronic non-malignant pain that has not been resolved by non-specialist services in the primary care setting.

Specialist interventions should be considered as one element of a multidisciplinary approach to managing chronic non-malignant pain in adults, rather than being used as standalone treatments. The use of specialist interventions should facilitate access to other support and procedures to help address the underlying causes of pain. All specialist interventions must be preceded by a detailed discussion between the patient and a chronic pain expert as part of an informed consent process. Points for discussion include:

the potential benefits and harms of the intervention(s)
the variations in the duration of pain relief experienced by patients receiving the intervention(s) and that the pain relief will be temporary
how the intervention(s) would be integrated within a wider programme of care designed to meet the needs of the individual patient
the uncertainty around the effectiveness and safety of repeating the intervention(s) over the long term.

The following specialist interventions should be available for consideration as part of a holistic chronic pain service within NHSScotland:

facet joint injections of local anaesthetic with or without steroids for adults with chronic pain of facet joint origin
interlaminar epidural injections of local anaesthetic with or without steroids for adults with chronic neck pain
sacroiliac joint injections of local anaesthetic plus steroids for adults with chronic low back pain of sacroiliac origin
continuous radiofrequency ablation (RFA) targeting nerves supplying the knee for adults with chronic knee pain
continuous or cooled RFA for adults with chronic sacroiliac joint pain
intravenous (IV) lidocaine infusions for people with chronic neuropathic pain where targeted interventions such as spinal injections or RFA are not appropriate.

All patients undergoing one of these specialist interventions should have a timely review to assess ongoing benefits or emerging harms to inform subsequent care decisions.

Chronic pain services should routinely gather standardised patient-important outcomes data on the use of specialist interventions. Outcomes data should include, as a minimum, pain relief, improved function and quality of life.

NHSScotland is required to consider the Scottish Health Technologies Group (SHTG) recommendations.

1. The Council recognised that individuals’ experiences of chronic pain are subjective and vary considerably based on demographic, biological and psychosocial variables such as sex, cultural background, genetics and personality.

2. The Council acknowledged that pain relief is only one of several important outcomes for people with chronic pain and that the focus on pain scores and function reflected the limited range of outcomes reported in the published literature. The Council highlighted that more research was needed on outcomes that matter to patients, including quality of life, sleep and social engagement.

3. The Council discussed the robustness of the published evidence across all specialist interventions for different types of chronic pain. The Council’s view was that the evidence was of sufficient quality and quantity to support the availability of the interventions as set out in their recommendations. In considering the evidence available to them, the Council highlighted the importance of the lived experience described by patients and patient groups.

4. The Council noted that some of the studies included in the systematic reviews were published more than 25 years ago, though this generally only applied to one or two primary studies within each review.

5. The Council discussed the importance of a multidisciplinary approach to managing chronic pain as part of an integrated model of care built around patients’ needs. It was recognised by the Council that pain relief from specialist interventions is temporary and rather than being seen as standalone treatments, specialist interventions should facilitate access to other support and procedures to help address the underlying causes of pain.

6. The Council recognised that their recommendations include interventions (IV lidocaine) that are being used outwith their marketing authorisation, which is referred to as ‘off-label’ use. The Council was reassured that clinical decisions would take into account the licensing of any intervention(s) being used. The prescriber must be competent, operate within the professional code of ethics of their statutory bodies and the prescribing practices of their employers.

7. Clinical experts at the Council meeting highlighted the comprehensiveness and robustness of the evidence review presented to the Council. The experts subsequently drew attention to the limitations of the published literature in determining the provision of chronic pain services, noting the importance of clinical experience.

8. The Council discussed the potential harms associated with the specialist interventions being considered. Although the published literature reported only minor harms, one clinical expert stated they were aware of instances of severe adverse effects after spinal injections for chronic pain. They also described emotional harm to patients who were unable to get repeat injections or who had their pain recur between treatments.

9. Clinical experts at the meeting commented on the financial and opportunity costs of specialist interventions for chronic pain. The Council noted the absence of cost effectiveness evidence to inform their decision making, including the paucity of comparative clinical outcome data. Opportunity costs included the potential impact of reduced theatre time available to treat patients cared for by other specialities.

10. The Council valued the input from patient groups and individuals with chronic pain who described the negative impact that chronic pain has on everyday life. The patient groups highlighted the association between chronic pain and elevated suicide risk.

11. With specific reference to IV lidocaine infusions, patients described to the Council the transformative effects of specialist interventions on their lives, enabling them to get up, take their children to school and re-engage in the workforce.

12. The patient groups highlighted their concerns around the exclusion of patients from decision making on the availability of chronic pain services in Scotland and the resulting perceived lack of patient focus. The Council discussed this issue with the patient groups and clinical experts, who all noted the value of inclusion and working together.

13. The Council acknowledged that offering repeat IV infusions, injections or RFA would increase service pressures and likely result in increased waiting lists. To help mitigate these concerns, the Council noted the importance of all patients having their treatments reviewed to gauge effectiveness and inform subsequent care decisions.

14. The Council noted the recent publication of the first part of the SIGN chronic pain guideline update. The guideline covers the management of adults with chronic pain in non-specialist healthcare settings that are not specifically designed for treating chronic pain, that is, an earlier part of the patient care pathway. It can be accessed through the SIGN website.

1. The evidence we reviewed had methodological limitations, including high heterogeneity that prevented comparative meta-analysis in some reviews, inconsistent definitions of chronic pain and clinical significance, inadequate reporting of patient characteristics, small sample sizes in the primary studies and reporting of a limited range of outcomes. These limitations of the published literature made interpretation of the evidence base challenging.

IV lidocaine infusions

2. A systematic review of 27 studies (n=358) found that IV lidocaine infusions provided a statistically significant but short-lived (generally a few hours or days) reduction in pain scores compared with placebo for people with chronic neuropathic pain. The clinical significance of the review findings was unclear because effect sizes were not reported for many of the primary studies.

3. Adverse effects from IV lidocaine infusions were mild and reported by relatively few patients. The most common adverse effects were light headedness, fatigue and nausea.

Spinal injections: facet joint injections

4. In a single-arm meta-analysis (21 studies, n=2,370), facet joint injections of local anaesthetic with or without steroids resulted in statistically and clinically significant reductions in pain scores for up to 12 months in patients with chronic spinal pain of facet joint origin. In meta-analyses (three studies, n=320) comparing injections of local anaesthetic alone with local anaesthetic plus steroids, there were no statistically significant differences between groups in pain reduction or function improvement.

5. A systematic review of eight randomised controlled trials (RCTs, n=587) found that facet joint injections were associated with an overall 31% reduction in pain scores and a 12.6% improvement in disability scores after 6–12 months follow-up in patients with facet joint osteoarthritis.

6. The most common adverse effects associated with facet joint injections were a temporary increase in low back pain (20% of patients in one RCT, n=25) and discomfort (44% of patients in one RCT, n=99).

Spinal injections: epidural injections

7. A systematic review with comparative and single-arm meta-analyses of four RCTs (n=370) found that cervical interlaminar epidural injections of local anaesthetic alone or local anaesthetic plus steroids were associated with statistically significant reductions in pain scores and neck disability scores for up to 12 months in adults with chronic neck pain.

8. A systematic review with comparative meta-analysis of ten RCTs (n=1,111) found no statistically significant differences in pain reduction or function improvement between epidural injections with local anaesthetic alone or local anaesthetic plus steroids in patients with chronic low back pain associated with disc herniation or lower limb radiculopathy. Duration of follow-up was not reported.

9. A systematic review of 52 RCTs (n=6,354) assessing epidural injections for treating chronic back pain with different causes reported mixed findings. While most studies demonstrated pain reductions, results varied and no effect sizes were provided. Results were not reported separately for injections with and without steroids.

10. Adverse effects were reported for less than 10% of patients across studies that recorded safety outcomes for epidural injections. Examples of adverse effects included temporary soreness around the injection site. No serious adverse effects were reported.

Spinal injections: sacroiliac joint injections

11. A systematic review with single-arm meta-analysis of 14 studies (n=983) found statistically and clinically significant reductions in pain scores with sacroiliac joint injections of local anaesthetic plus steroids in patients with chronic back pain of sacroiliac origin after 3 and 6 months follow-up. Statistically significant improvements in function were reported after 3 and 6 months follow-up, but were clinically significant only at 3-months follow-up. A lack of comparative analysis means it is unclear whether adding steroids to local anaesthetic injections offers additional benefits.

12. Safety outcomes relating to sacroiliac joint injections were not reported in the systematic review.

Radiofrequency ablation (RFA) for joint pain

13. Continuous or pulsed RFA targeting the nerves supplying the shoulder joint may reduce pain and improve shoulder function in patients with chronic shoulder pain, but the magnitude and clinical significance of the effects are uncertain.

A systematic review of 29 studies (n=1,174), that did not report effect sizes, concluded there were statistically significant reductions in chronic shoulder pain scores and improvements in function scores 3–6 months after RFA.
A systematic review with comparative meta-analysis (eight RCTs, n=428) found no statistically significant differences in pain reduction or shoulder function between patients treated with RFA and those who received an active comparator or placebo after 1–3 months follow-up.

14. A health technology assessment (HTA), based on a systematic review of 26 studies (number of patients unclear), concluded there was insufficient evidence to determine the effectiveness of continuous RFA for treating chronic hip pain.

15. An HTA (two systematic reviews and two primary studies, n=491), a systematic review (19 studies, n=145) and a systematic review with a single-arm meta-analysis (eight studies, n=256), reported that RFA targeting the nerves supplying the knee led to statistically significant reductions in pain scores and improvements in function for up to 6 months in patients with chronic knee pain. The magnitude of these effects varied across the primary studies included in the reviews.

16. Adverse effects were reported only in studies assessing RFA for chronic knee pain. They were reported in the minority of studies and were not serious. Examples include subcutaneous bleeding around the knee, temporary numbness or transient pain.

RFA for spinal pain

17. In a systematic review of eight studies (number of patients unclear), thermal RFA targeting cervical spinal nerves to treat chronic neck pain was associated with complete pain relief for 46% to 70% of patients at 6-months and 20% to 51% of patients at 12-months follow-up.

18. A systematic review with comparative meta-analysis of 19 RCTs (n=1,530) found evidence that continuous RFA provided statistically significant short-term pain relief (<3 months) compared with sham controls in patients with chronic low back pain associated with the sacroiliac joints. The clinical significance of this result was unclear. No statistically significant differences between RFA and sham controls were reported for other RFA targets, such as facet joints or intervertebral discs.

19. A systematic review with comparative and single-arm meta-analysis (21 studies, n=1,947) found that RFA resulted in a statistically significant reduction in chronic sacroiliac joint pain at 3 and 6 months follow-up compared with active controls. It is unclear whether the difference between groups was clinically significant. In single-arm meta-analyses, there were statistically and clinically significant reductions in pain and improvements in function for up to 12 months after RFA.

20. A systematic review with single-arm meta-analysis (seven studies, n=240) evaluating cooled RFA found statistically and clinically significant reductions in pain and increased function at maximum follow-up (3–24 months) in patients with chronic sacroiliac joint pain.

21. No serious adverse effects were reported after the use of RFA to treat chronic spinal pain. Non-serious adverse effects were reported in a minority of studies and included symptoms such as a burning sensation and temporary pain.

22. Three economic evaluations assessed the cost effectiveness of RFA compared with exercise programmes (two studies) or conservative management (one study) for treating patients with chronic low back pain. None of the studies used a United Kingdom (UK) NHS perspective and results were not generalisable to Scotland. Results from the studies were heterogeneous and contained substantial uncertainty.

Comparing spinal injections with RFA

23. Three network meta-analyses (NMA) and two systematic reviews (136 studies, total n=12,187) compared spinal injections with RFA for the treatment of different causes of chronic spinal pain. Results for pain relief and function improvements varied across analyses, with authors reporting either no statistically significant differences between interventions or statistically significant improvements in the RFA groups compared with the spinal injections groups.

Patient and social aspects

24. Two grey literature reports (interviews, n=92; survey, n=462) found that chronic pain affected all aspects of people’s lives, including daily activities, work and relationships. Living with chronic pain negatively impacted people’s quality of life, mental health and well-being, sense of identity and social engagement.

25. Two grey literature reports (interviews, n=92; survey, n=462) and a systematic review of qualitative studies that used a survey (n=1,219) to validate the results of their review, described four themes from patient experiences of chronic pain:

a lack of knowledge and understanding about chronic pain among healthcare professionals, carers, family and friends
long waiting lists and delays in accessing treatment
barriers to accessing chronic pain services, particularly specialist pain services
poor communication between healthcare services and patients.

26. In a comparative meta-analysis of 19 observational studies (n=3,312,343) in patients with different types of chronic pain, the lifetime prevalence of suicidal ideation was 28.90% (95% confidence interval [CI] 17.95% to 41.26%) and the lifetime prevalence of suicide attempts was 10.83% (95% CI 5.72% to 17.30%). In another comparative meta-analysis of 88 studies (number of patients unknown), people with physical pain of any duration were twice as likely to exhibit suicidal behaviour or attempt suicide compared with people without physical pain.

27. A primary study analysed user comments (n=405) posted on the Reddit online forum about RFA treatment for chronic pain. Of the 405 comments, 187 users reported improved pain and 130 reported no meaningful change in their pain after RFA. Among 96 comments that mentioned the duration of pain relief, the range was 4 days to 3 years. Fifteen users reported that the pain relief was shorter than expected.

28. A patient organisation submission from the Scottish Cross-Party Group on Chronic Pain reported that:

there is substantial variation in the availability of specialist interventions across health boards in Scotland
patients found the effects of specialist interventions to be life changing, allowing them to resume a near-normal life and to reduce their reliance on opioid medications
untreated chronic pain is linked with an increased risk of suicidal behaviour
four out of five people with chronic pain contacted at least one NHS unscheduled care service in Scotland over a 3-year period
patients in Scotland are experiencing long delays in accessing chronic pain services, including appointments for repeat interventions
for some patients IV lidocaine infusions were effective for up to 8 weeks.

Output Type

Recommendation

Speciality

Nervous system, Patient experience, Musculoskeletal system, Public health

Published

27 February 2026

Referring Organisation

Scottish Pain Medics National Network

Specialist interventions for managing chronic non-malignant pain in adults

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