Quality prescribing for chronic pain 2026-2029: consultation

7. Consultation conversations

7.1 Introduction

Around one in three of the population experience chronic pain in some form. It should be acknowledged that this is a difficult area for society in general, and medicine in particular, to manage. Individuals should be reassured that they are not alone and should be reassured that their healthcare team will keep working for the best outcome that they can achieve. Evidence in this area is limited, however, the recommendations in this chapter are intended to be pragmatic suggestions based on specialist experience and current published data.

The flowchart below illustrates how primary care teams can manage and support individuals with chronic pain.

7.1.1 Multidisciplinary team management

The process below described how primary care teams can manage and support individuals with chronic pain. It is also available as a flow chart within the supplementary documents associated with this guide.

First consultation

• Consider differential diagnosis (exclude red flags, assess mental health)
• Validate pain and offer support
• Give information – explaining condition, limits of medications (for most people they are ineffective, and for those that do benefit a 30% reduction in pain or a 30% improvement in function is considered effective), self-management
• Consider Physio/OT support if difficultly or disruption with daily activities, roles responsibilities

Subsequent appointments will dependent on information obtained during first consultation, but appropriate clinicians may include:

Physio/OT (if available)

• Identify functional deficits and goals
• Rehab approach; education, coping strategies, aids and adaptions, self-management support
• Refer to GP (or ANP) if individual is not progressing, increasing distress, new health issues identified

GP (or ANP)

• Investigating pathology
• Pre contemplative about pain being a long-term condition – ‘wanting a fix’
• Multiple ongoing issues
• High distress
• Consider referral to OT/Pharmacist when stable as per inclusion/ exclusion criteria

Pharmacist

• Analgesic polypharmacy high dose opioids, two step 2 opioids
• Medicines management
• Education
• Self-management support
• Refer to GP (or ANP) if individual is not progressing, increasing distress, new health issues identified

Second line options may include:

Pain team referral

• Ongoing debilitating pain
• Open to rehabilitation working
• No improvement despite multiple reviews
• Not awaiting other hospital interventions

Practice MDT/pain team advice

• No improvement despite multiple reviews
• Not open to rehabilitation working
• Ongoing distress with pain
• Harmful polypharmacy
• Suspected drug seeking behaviour

7.2 Primary care consultation model

This section offers suggested structure and phrasing. It is based on clinical experience which incorporates the realistic medicine theme of "what matters to you?" and is informed by the 2019 SIGN 136 Chronic Pain ^[16] and 2021 NICE Chronic Pain guidelines ^[17],[18]. It is important for each practitioner to discuss pain management in ways authentic to them and sensitive to the individual’s needs. The goal is to have meaningful conversations which build trust and develop shared decision making^[19]. The 10 top tips video from Dr Tim Williams is a helpful resource.

Chronic pain is a long-term condition. It cannot be ‘fixed’ or managed in an initial 10-minute consultation often when an individual is in crisis and distressed. To reduce clinician stress and have a more effective consultation, it helps to instead focus on listening to the individual’s story, validating and building trust. This approach helps to create person-centred working with individuals becoming more receptive to education on pain and supported self-management. Individuals often have a complex back story of emotional suffering, trauma, loss, anger, health beliefs and feelings of being let down or not believed by medical professionals. Trauma-informed care would encompass working to build feelings of trust, choice, empowerment, safety and collaboration within the consultation.

7.2.1 Consultation 1: build trust, exclude differentials

1. Introduce yourself, your role and acknowledge the person in front of you, assisting with the connection and building trust. Tread gently and reassure them that the conversation will be centred around what matters to them and considering the 7-Steps approach.

2. Assess for and manage red flag symptoms^[20], active mental health problems and the individual’s health beliefs before focusing on pain management. Identify any social challenges e.g. inadequate housing, financial issues or relationship difficulties. Questions to identify health beliefs can include: “What do you think is happening to cause the pain? I have my own thoughts but want to check first, what were you hoping for today?”

3. Validation – summarise their story back to them for example: “Ok I can see you are really suffering and I’m happy to work with you. Firstly let me check I’ve got this right. So X years ago you got X pain at X (part of your body). It’s affected your life especially X and you’ve tried X things so far. Have I got that right?”

4. Check level of awareness of current condition and what the individual expects of the outcomes of the consultation e.g. cure seeking vs wanting a pain management plan. This indicates whether the individual is ready for behaviour change. E.g. “Ok, before we go on can I check what’s your understanding of persistent pain and the outcomes you expect following today?”

5. Be open and candid about limits of medical intervention. Suggested phrases:

• Acknowledge the impact of pain on their life “The condition you have is (e.g. osteoarthritis, nerve pain, fibromyalgia, chronic back pain). It is a painful medical condition. Part of having a condition like this is that the pain is persistent. The pain will vary and you may experience flare ups, depending upon many factors, such as how well you respond to various approaches. Most people wish that their pain could be taken away; this is normal.”
• Acceptance of where the person is at that moment, we cannot fix it but can improve management“I need to be honest here, chronic pain is a long-term condition and unfortunately isn't curable with medication. For most people, pain medication is not effective and even when they work well, they only give around a 30% reduction in pain and can cause side-effects such as drowsiness, dizziness and constipation.”
• Agree a plan “We know pain management is improved by understanding pain better (everything that matters to you matters to your pain). The goal is to manage it so it doesn't manage you. For example, we know that becoming more active, even slightly, can help pain. Understanding sleep and relaxation can help pain. Reducing worries and fears can also help manage pain. Understanding your pain is the first step. Here are some resources that you might find helpful. I know this is hard so can you book a follow up consultation with me once you've been through the resources?”
• “We can work together to develop a personalised plan that works for you, giving you a package of management skills that you can use in everyday life. This is a combination of information, treatment and support. Here are some resources that you might find helpful. I know this is hard so can you book a follow up consultation with me when you are ready, I suggest 4 weeks, after you've been through the resources.”

“The condition you have is (e.g. osteoarthritis, nerve pain, fibromyalgia, chronic back pain). It is a painful medical condition. Part of having a condition like this is that the pain is persistent. The pain will vary and you may experience flare ups, depending upon many factors, such as how well you respond to various approaches. Most people wish that their pain could be taken away; this is normal.”

“I need to be honest here, chronic pain is a long-term condition and unfortunately isn't curable with medication. For most people, pain medication is not effective and even when they work well, they only give around a 30% reduction in pain and can cause side-effects such as drowsiness, dizziness and constipation.”

“We know pain management is improved by understanding pain better (everything that matters to you matters to your pain). The goal is to manage it so it doesn't manage you. For example, we know that becoming more active, even slightly, can help pain. Understanding sleep and relaxation can help pain. Reducing worries and fears can also help manage pain. Understanding your pain is the first step. Here are some resources that you might find helpful. I know this is hard so can you book a follow up consultation with me once you've been through the resources?”

6. Offer support, resources and continuity. Consider learning style e.g. “How do you like to learn new information? For example are you a reader, go online, a people person or prefer one to one? Do you need support to learn new things? “Here are some tools that many people living with pain find helpful (NHS Inform chronic pain resources). When we speak again it’s fine to bring someone if that would help.”

7. Medicines management

• Be clear medication is to improve function and will be stopped if ineffective
• If significant polypharmacy or a risk of harm then ensure reauthorise function on Vision is activated or put medication on acute on EMIS. This can help avoid people being lost to follow up
• Once the medication is reviewed and is to be continued, place on repeat with a limited issue allocation and set a review date. Vision has the facility to set a minimum reorder time. For example, for 28 day prescribing a minimum reorder time of 25 days could be set, to prevent overordering.
• If starting a medication, ensure that it is reviewed regularly, stating a follow up time frame

8. Coding – use the following read codes:

• #1M52 for diagnosis of chronic pain
• #66n for chronic pain review
• 8B31B for polypharmacy review

7.2.2 Consultation 2: pain management plan

What's the matter?

1. Follow-up on resources signposted to the individual.

2. Explore the type of pain, e.g. musculoskeletal or nerve pain. Consider using S-LANSS questionnaire^[21] to determine if the pain has neuropathic pain.

3. Consider the impact on mood and life. “People living with pain often have problems with their sleep, mood or relationships, does that happen to you?”

4. Consider baseline scores – “On average what is the impact of pain on your day to day life over the last two weeks? Out of 10 with 0 meaning no impact and 10 being unable to get out of bed.”

5. Discuss activity - Identify underactivity or overactivity, or cycling between the two. Introduce pacing. “Often people can do too much then hit the wall – does that happen to you?”

6. Medication review – “Being honest, do you think the medications make a difference or is it hard to tell? Do you get any of these common side effects…?”

What matters to you?

7. Summarise their story, acknowledge impact on life and offer continuity. Acknowledge pain in the context of the whole person e.g. work, family life. “Looking forward to the next three months what things matter the most in your life? What would you like to improve?”

Support for what matters to you

8. Review their learning style and any barriers, match to resources

9. Offer specialist support – pharmacist, physiotherapy, occupational therapy, mental health support, community link workers, third sector

10. Deprescribing –– “If a medicine isn’t helping you then it can be harming you. Can we work together to slowly reduce it and see if this reduces some of your symptoms, which may be side-effects of the medicine?”

11. Offer clinician follow up and read code in EMIS/ Vision using “Chronic pain review/ #66n”

7.2.3 Consultation 3: promote self-management

1. Ask if there has been some improvement or if the person feels better – if so what has helped? Acknowledge and reinforce strengths and efforts to help build self-efficacy. Consider asking the individual to document changes and interventions.

2. If there is little or no improvement or if the individual is not satisfied – check that the clinician relationship with the person is constructive, work through options for self-management and use of medication. Consider barriers such as other causes of pain, active mental illness, lack of understanding, fixed health beliefs or motivation issues.

3. If there is still no improvement after several consultations consider referral to specialist chronic pain service. “They don’t cure pain but they are a rehab service to help you improve your quality of life. What do you think about being referred?”

Personal reflections from general practice on a change to managing chronic pain

“To be honest, prior to our practice learning on chronic pain we did not really understand pain. When someone presented with pain, medication was started or increased to see if it would help.

After completing a pain course with a local pain consultant, our understanding of chronic pain has made us aware that starting or increasing the pain meds is not the answer. It is more complicated and often more time consuming than giving someone a prescription. The knowledge we have gained has been invaluable and has given us the confidence to approach the subject of chronic pain with our patients who are on medication for it, especially if they are still in pain but on lots of pain meds.

Taking a whole team approach with support from external sources was really helpful. It showed that as clinicians, we don’t always have the knowledge about pain and how it affects a person, how complex it is and how much it can debilitate a person and their family. Managing pain does require spending a bit more time listening to the individual and using a shared decision making approach to the pain meds, but it really works. It is really gratifying to see a person who was a shell of themselves change into a person who can function and enjoy life to the full again.

Our next step is to send letters to those who are on pain meds to offer them an appointment to come in and discuss their pain with a clinician, offering them support and information and encouragement to look at their pain meds with the aim of deprescribing.”

7.3 Pain consultation tool

The Pain Consultation Tool is designed to assist your understanding of where your patient may be in terms of behaviour change. It is not meant to replace usual treatment, simply to guide the timing of your interventions focused on supported self-management.

Table 1: Pain consultation tool

Main theme

Level 1 Not aware it’s a Long-Term Condition (LTC)

Description

Feels overwhelmed. Not aware of self-management. Consider trauma background, active mental health issues and problematic substance use

Individual’s perspective

“I need something to fix it. Is there an underlying disease?”

Individual’s characteristic

Passive, uninformed, resistant, distracted. May be angry, defensive or distressed. May still be grieving loss - or stuck

Questions

“What’s your understanding of pain?”

Interventions Prioritise based on level

• Relationship building
• Listen
• Validate
• Educate
• Normalise
• Signpost

Main theme

Level 2 LTC-aware but overwhelmed

Description

Knows they could be self-managing more but doesn't yet have knowledge and skills to do so.

Individual’s perspective

“I'll give it a go, but I don't expect it to help”

Individual’s characteristic

Ill-informed about factors influencing pain, the costs of actions and how to intervene/change

Questions

“How have you tried to help manage pain? How well have these worked for you in the longer term, as well as short term?”

Interventions Prioritise based on level

• Support Team
• Individual
• Support network
• Third sector
• Practice MDT

Main theme

Level 3 LTC-aware but low confidence

Description

Knows roughly what they can do to influence pain, but not confident to change behaviour.

Individual’s perspective

“I want to learn to manage pain, but I need help”

Individual’s characteristic

Frustrated, discouraged, oscillates in determination and motivation

Questions

“What things are most useful?”

Interventions Prioritise based on level

• Pain Management Plan
• Values based goal setting
• Support emotional wellbeing

Main theme

Level 4 LTC-aware usually confident but having a setback

Description

Generally managing well and has good self-management behaviours, but set back due to stressors or life circumstances

Individual’s perspective

“I know I can do it, but I don't know how to get past this obstacle”

Individual’s characteristic

Determined but discouraged

Questions

“Any triggers that might have caused this?”

Interventions Prioritise based on level

• Common issues (and solutions)
• Unclear goals (SMART goals)
• Lack support (support team)
• Boom/bust (pacing/activity plan)
• Flares (flare up plan)

(Adapted and reproduced with kind permission from the NHS Grampian Chronic Pain Service)

7.4 Summary of consultation model

Below is a summary of the primary care consultation model. It can be adapted based on the individual’s stage of change (level one to four).

Validate- Validation is the recognition and acceptance of another person's thoughts, feelings, sensations and behaviours as understandable.

It can be helpful to summarise what you have heard; i.e. “I understand that you feel this pain has taken away a lot of the things you enjoyed doing.” Validation does not mean agreeing.

Values and goals - Help individual to identify the ‘who or what’ matters to them.

Sometimes people will say things like “to get back to how I was before.” A useful response is “do you think that is realistic?” and they will usually agree it is not realistic. This builds an acceptance of a ‘new normal’ for the person.

What matters most to the person? This usually starts with an initial “to feel better” but when specified it is often practical things that matter; such as getting out more, housework, playing a more active family role, staying in work.

Discuss appropriate goals with the individual.

Educate/normalise - Explain to the individual the difference between short and long term pain. Tissue damage vs active nervous system.

Signposting

• National guide: NHS Inform Chronic Pain
• Explanation videos:
  • Tame the beast
  • understanding pain in less than 5 minutes
  • Flippin Pain
• Condition Specific: Flippin Osteoarthritis and Flippin Fibromyalgia

Support options

• Relatives, Pharmacist, Physiotherapist/OT, Mental Health Liaison Nurse, Community link worker.
• Third Sector:
  • Pain Concern – 0300 123 0789
  • Versus Arthritis – 0800 5200 520
  • Pain Association Scotland

Pain Management Plan

• Give key messages around holistic approach and limits of medication.
• Agree prescribing e.g. trial, based on individual’s goals and review. Stop if no improvement in function.
• Live Well with Pain 10 Footsteps for Rehabilitation Plan

Flare up plan

• NHS Inform flare plan

Clinician resources

• Live Well with Pain 10 footsteps a practitioners guide
• Primary Care MDT Toolkit – see this resource for example letters to patients

7.5 Useful phrases

Table 2 below brings together some useful phrases to use in various contexts.

Key point

Validation

Promote

Active listening

“That sounds really tough.”

“You are not alone.”

“Your pain is real.”

Avoid

“Lots of people have your problem.”

Key Point

Partnership working

Promote

“I’m happy to work with you but we need to work in partnership.”

Avoid

“You need to manage it yourself.”

Key Point

Values led management plan

Promote

“What are things that are important for you to be able to do?”

Avoid

“What are your goals?” (may be interpreted as what am I expected to do)

Key Point

Pain

Promote

Understanding the difference between acute and chronic pain

Avoid

“Your pain is not real – it's all in your mind.”

“There is no damage or cause for your pain.”

Key Point

Being honest while giving hope

Promote

“I need to be honest, this is a long-term condition. There are lots of things that can help but there isn’t a magic tablet or intervention that will cure it.”

Avoid

“X medication or intervention will cure this.”

“Nothing can help.”

Key Point

Chronic pain management

Promote

“The evidence tells us that chronic pain is best managed a bit like a jigsaw, piecing all the right bits for you together. This all works together to retrain your pain-sensor system.”

Avoid

“There’s nothing we can do.”

“You have to manage it yourself.”

“(Just) take this medication...”

Key Point

What works

Promote

“We know pain management is improved by understanding pain better - everything that matters to you matters to your pain.”

“Things that make a difference to pain include: activity, sleep, relaxation, mental health, stress management and emotional well-being.”

“Understanding your pain is the first step. Here are some resources that you might find helpful.”

“I know this is hard so can you book a follow up appointment in (I suggest) four weeks, once you have been through the resources?”

Avoid

Stating that there are cures available or conversely that nothing works

Key Point

Mood and mindset

Promote

“Pain and mood are connected - can I check how you are feeling?”

Avoid

Viewing pain only through a biomedical lens

Key Point

Low back pain

Promote

“Spine joints, discs and cartilage are very strong, and it takes a lot of force to damage them.”

Avoid

“Pain is due to severe damage or crumbling bones” – causes a fear response and heightens pain signals

Key Point

Imaging

Promote

“Scans show normal age-related changes.”

“Your joints are showing signs of normal ageing.”

“The body continuously wears and repairs throughout life. Just like wrinkles on the skin, joints also show wrinkles over time.”

Avoid

“There is damage.”

“There is wear and tear.”

Key Point

Medication

Promote

“Medication may have a role but only as part of a wider management plan. The most effective medication is one that helps at the lowest effective dose with minimal side effects. We can try a medication but if it’s ineffective then we’ll stop it.”

Avoid

“This tablet will fix it.”

Avoid prescribing without it being part of a plan.

Key Point

Movement

Promote

“Physical activity is important to maintain strength and flexibility, and this helps you with your everyday activities. It helps you feel better as it releases the body’s own feel-good chemicals.”

“Let's work together to find safe ways for you to move again.”

“Let’s find something you enjoy doing.”

Avoid

“You need to exercise.”

“Hurt causes harm.”

7.6 Recognising and responding to drug seeking behaviour

Opioids and gabapentinoids have a limited role in managing chronic pain and are known to be dependence forming medications (DFM). Dependence in this case is defined as the need to continue taking a medicine to maintain a state of normality and avoid symptoms of withdrawal.^[22]

Harm from prescribed DFMs is increasing in Scotland^[23], which includes death from overdose. Healthcare professionals should be aware of behaviours that may indicate drug seeking, and that drug seeking behaviour may not be obvious^[24]. Prescribers should be mindful of the risk of diversion of opioids and other DFMs and consider the implications of prescribing.

Safety must be the first consideration. Refer to the checklist below to help identify common features of drug seeking behaviour.

Checklist of common features relating to drug seeking behaviour:

• Specific request for an opioid or a gabapentinoid
• Request for a prescription for a drug of dependency or prone to problematic use (gabapentinoids, benzodiazepines, z-drugs and combinations thereof)
• Previous episodes of drug seeking documented in patient notes, special notes or system warnings
• Unwillingness to try simple analgesia
• Unexpectedly high doses of analgesia required (primarily opioid but may include gabapentinoids)
• Vague intolerances of alternative or simpler analgesia
• Demanding or aggressive behaviour
• Drug seeking suspected by a colleague
• Inconsistent history and examination findings
• Multiple presentations with the same complaint at primary or acute sites or services including Out of Hours
• Differing history given to different staff members or services (account given to NHS24 may differ to that of the triaging clinician, which may then also be different from the account given if seen face to face)

The MDDUS (Medical and Dental Defence Union Scotland) have provided helpful advice on prescribing controlled drugs.

There should be respectful, non-stigmatising approaches to assessment which takes into account the person’s circumstances including^[25]:

• Physical and mental health
• Personal, social, educational or employment circumstances
• Any drug use
• Safety of person being assessed

Offer clear information on DFMs and their effects, including risks and benefits. Provide information and signposting to support individuals to make a shared decision. Useful prescriber tools and information include:

• Opioid side effect lottery
• Opioids aware
• Opioid thermometer tool
• Dealing with drug seeking behaviour webinar

Set ground rules around prescribing DFMs and schedule regular reviews. Watch out for polypharmacy and co-morbidities. Support individuals to reduce or stop if the medicines are not wanted, needed or working. Tapering DFMs requires careful planning and collaboration and should not be done abruptly. Tapering of opioids is explored in Chapter 10: Opioid management general principles and detailed in Appendix F.

Be alert to signs of drug seeking behaviour and emerging dependence or addiction. Consider professional responsibilities for any prescribing, so that any prescription is safe and appropriate for that individual. Operate within guidance on prescribing, including private prescribing, and refer to local formularies and guidance. Consider a practice-wide system and process for DFMs and apply this consistently. There is an example of a practice protocol in Appendix D, which can be adapted for local practice, cluster or board use. Some practices use a ‘patient contract’ which sets out expected behaviours and agreements for both parties when starting to prescribe a DFM.

Useful phrases that can help in conflict situations

‘Thanks for being honest about what you want. I will be honest too. These medications are not recommended for long term pain management. They are often harmful for people, and we are responsible for safe prescribing. If you want a second opinion you can speak to another clinician in the practice. I'm happy to work with you on managing this better but need to be honest.’

If the individual persists with their request, and ends up in a circular conversation, a useful approach is to say, ‘we've discussed this already, is there anything else you want to talk about’. If they persist, then say ‘the answer is no.’

An alternative approach may be to say, ‘I'm not able to prescribe that but if you want, I can discuss with one of the senior staff and then phone you back.’ This helps to defuse a potentially heated situation and let the individual phone back later which can be safer in a conflict situation.

Areas of concern:

• ‘Medicines are not working’ – review and stop them, as with other medication
• Underlying condition resolved, but individual still taking medication
• High doses (e.g. over 90g morphine equivalent dose), especially when co-prescribed with other DFMs (gabapentin, pregabalin, benzodiazepines, z-drugs)
• Has the individual’s condition changed? For example, intercurrent illness, getting older, renal or hepatic function compromised – a dose reduction will be needed to avoid toxicity

Be aware of information on local substance use services and where to find local advice and support for dependence on prescribed medicines.

Tools for prescribers:

DIRE score for opioid treatment - predicts compliance with opioid treatment for non-cancer pain. DIRE score of 7 – 13 indicates that the individual is not a suitable candidate for long term opioid analgesia, 14 – 21 indicates a good candidate.

Opioid Risk Tool (ORT) – may help identify those at high risk of problematic substance use and who might benefit from other modalities of pain control besides opioids. Questions assume some knowledge of medical history.

7.7 Framing a pain consultation

The following are acronyms that may help frame a pain consultation:

HOPES

H: Hear the story - active listening with empathy for impact on life

O: Other causes considered - assess for organic pathology and active mental health problems

P: Plain explanation - that chronic pain is a long-term condition, it's not 'fixable' but goal is improved function and quality of life. Be honest about the roles and limits of medications and other interventions

E: Engage - by asking what matters most in their lives, what they want to do? Integrate a medication review if appropriate

S: Supported self-management plan - using online resources, support network, third sector, primary care MDT and other NHS resources

SUGAR

S: Self-management and social prescribing - Link with local groups or activities to help reduce social isolation, improve mood, increase physical activity and so improve quality of life. Also direct individuals to self-management resources.

U: Understanding pain and the individual - Discuss what chronic pain is to help people improve their understanding of chronic pain and how it can be managed. This is reassuring for individuals and helps them to understand that chronic pain can exist without serious underlying cause, while still being a very real pain. Communication and listening are key to finding out what is important to people and how chronic pain affects their daily life.

G: Goal setting - Discuss and agree achievable realistic goals to engage people in their treatment and to help them assess their progress.

A: Acceptance – Assist people to accept that chronic pain is a long-term medical condition. Emphasise that further investigations or surgeries may not be useful. Accepting that they can make changes to their lives to help manage their pain is important. This helps them to take control of their lives again.

R: Relationship, reducing medication and review - Build rapport and trust before attempting to reduce medication. The decision to reduce medication should be a joint one, with a plan agreed between clinician and individual. Regular review and support is essential.