1. Social interventions
1.1. Review question: What is the clinical and cost effectiveness of social interventions aimed at improving the quality of life of people with chronic pain?
1.2. Introduction
Social factors may have profound effects on the experience of pain. Suffering chronic pain can also have profound social effects. Inability to complete certain tasks or, for example, to go out with friends can cause loss of social status or loss of work, which impact both self-esteem and financial security. Isolation and loneliness can soon follow. People with long-lasting, severe pain may need to change job, work less and/or give up work altogether. The financial insecurity caused by the experience and prospect of loss of income can add to psychological stress. Poverty, stress and pain are closely interlinked. These factors all contribute to the experience of pain, and the way healthcare systems need to manage it. Being able to manage these factors successfully can transform people’s lives. While people may still be in pain, they may be better prepared to deal with it.
There are many initiatives to enhance the wellbeing of people with health conditions through engagement in meaningful social activities. Local charities and voluntary sector organisations harness the power of group activities in non-medical settings to empower individuals with a variety of conditions to manage their conditions more effectively. This is often called “social prescribing”. This chapter aims to assess the current evidence of such strategies in the management of chronic pain.
1.3. PICO table
For full details see the review protocol in Appendix A:.
Table 1
PICO characteristics of review question.
1.4. Clinical evidence
1.4.1. Included studies
No relevant clinical studies comparing social interventions with standard care were identified.
See also the study selection flow chart in Appendix C:.
1.4.2. Excluded studies
See the excluded studies list in Appendix I.
1.4.3. Summary of clinical studies included in the evidence review
No studies were identified.
1.4.4. Quality assessment of clinical studies included in the evidence review
Not applicable.
1.5. Economic evidence
1.5.1. Included studies
No health economic studies were included.
1.5.2. Excluded studies
No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.
See also the health economic study selection flow chart in Appendix G:.
1.6. The committee’s discussion of the evidence
1.6.1. Interpreting the evidence
1.6.1.1. The outcomes that matter most
The committee considered health-related quality of life to be the only critical outcome for decision-making, as improvement in quality of life is the primary aim of social interventions. Physical function, psychological distress, pain interference, pain self-efficacy, use of healthcare services, sleep, discontinuation and pain reduction were also considered to be important outcomes. The critical and important outcomes agreed by the committee were adapted by consensus from relevant core outcome sets registered under the Core Outcome Measures in Effectiveness Trials (COMET) Initiative. This included the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations.
No evidence was identified for any critical or important outcomes.
1.6.1.2. The quality of the evidence
No evidence was identified.
1.6.1.3. Benefits and harms
Although there was no evidence identified that was relevant to this guideline population, the committee highlighted non-randomised evidence in other populations. It was noted that this suggested a benefit of social interventions in populations broader than chronic pain, although there was uncertainty. Furthermore the NHS long term plan committed to building the infrastructure for social prescribing in primary care. The committee therefore agreed that it would be important for there to be specific research in the effectiveness of this in people with chronic pain and included a research recommendation on this topic.
1.6.2. Cost effectiveness and resource use
No economic evidence was identified for this question.
Social interventions are very variable, which means the costs are also variable. No clinical evidence was identified to provide information on the benefits of social interventions. Widely implementing social interventions in the NHS will have a large resource impact. Given the lack of evidence, a research recommendation was made.
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Appendices
Appendix A. Review protocols
Review protocol for social interventions (PDF, 228K)
Table 2. Health economic review protocol
Appendix B. Literature search strategies
The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.24
For more information, please see the Methods Report published as part of the accompanying documents for this guideline.
B.1. Clinical search literature search strategy
Searches were constructed using a PICO framework where population (P) terms were combined with Intervention (I) and in some cases Comparison (C) terms. Outcomes (O) are rarely used in search strategies for interventions as these concepts may not be well described in title, abstract or indexes and therefore difficult to retrieve. Search filters were applied to the search where appropriate.
| Database | Dates searched | Search filter used |
|---|---|---|
| Medline (OVID) | 1946 – 20 May 2020 | Exclusions Randomised controlled trials Systematic review studies |
| Embase (OVID) | 1974 – 20 May 2020 | Exclusions Randomised controlled trials Systematic review studies |
| The Cochrane Library (Wiley) | Cochrane Reviews to 2020 Issue 5 of 12 CENTRAL to 2020 Issue 5 of 12 | None |
| ASSIA (ProQuest) | Inception - 20 May 2020 | None |
| SPP (Ovid) | Inception - 20 May 2020 | None |
| CINAHL (EBSCO) | Inception - 20 May 2020 | None |
| King’s Fund | Inception - 20 May 2020 | None |
Medline (Ovid) search terms
Embase (Ovid) search terms
ASSIA (ProQuest) search terms
SPP (Ovid) search terms
CINAHL (EBSCO) search terms
King’s Fund search terms
Cochrane Library (Wiley) search terms
B.2. Health Economics literature search strategy
Health economic evidence was identified by conducting a broad search relating to a Chronic Pain population in NHS Economic Evaluation Database (NHS EED – this ceased to be updated after March 2015) and the Health Technology Assessment database (HTA) with no date restrictions. NHS EED and HTA databases are hosted by the Centre for Research and Dissemination (CRD). Additional searches were run on Medline and Embase for health economics and economic modelling.
Table 3. Database date parameters and filters used
Medline search terms
Embase (Ovid) search terms
NHS EED and HTA (CRD) search terms
Appendix C. Clinical evidence selection
Figure 1. Flow chart of clinical study selection for the review of social interventions
Appendix D. Clinical evidence tables
None
Appendix E. Forest plots
None
Appendix F. GRADE tables
None
Appendix G. Health economic evidence selection
Figure 2. Flow chart of health economic study selection for the guideline
Appendix H. Health economic evidence tables
None
Appendix I. Excluded studies
I.1. Excluded clinical studies
Table 4. Studies excluded from the clinical review
I.2. Excluded health economic studies
Table 5. Studies excluded from the health economic review
Appendix J. Research recommendations
J.1. Social interventions for chronic pain
Research question: What is the clinical and cost effectiveness of social interventions aimed at improving the quality of life of people aged 16 years and over with chronic pain?
Why this is important:
Social prescribing is included in the NHS long term plan as a component of Universal Personalised Care as it has been suggested to lead to a range of positive health and wellbeing outcomes. Social prescribing aims to take a holistic approach to people’s health and wellbeing, focusing on ‘what matters to me’. It can include referral to community groups or statutory services for practical and emotional support.
This is becoming part of the primary care service, however it is a relatively new approach to treatment and robust evidence specific to distinct populations and conditions is still lacking in many areas. Such research in people with chronic pain was lacking when searched for within this guideline, therefore future research directed to answer this question would be beneficial to help inform future updates of this guideline.
Criteria for selecting high-priority research recommendations
Intervention evidence review underpinning the research recommendation on social interventions in the NICE guideline
This evidence review was developed by the National Guideline Centre based at the Royal College of Physicians
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circ*mstances of the individual patient, in consultation with the patient and, where appropriate, their carer or guardian.
Local commissioners and providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
