Specialist interventions for managing chronic non-malignant pain in adults
Scottish Health Technologies Group (SHTG)
Recommendations for NHSScotland
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.
How the Council reached the recommendation
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
Date of publication: 27 February 2026