Quality prescribing for chronic pain: guide for improvement 2026-2029

1. Clinical foreword

The management of chronic pain is acknowledged to often be challenging, both for the individual living with chronic pain and for the clinician. The Scottish Government recognised chronic pain as a long-term condition in its own right in 2008.

With this guide, we aim to support clinicians managing chronic pain, particularly given the risks of adverse effects, potential for dependency and the association with polypharmacy, and the benefit of non-pharmacological options.

The understanding of chronic pain has moved away from the medical model and use of the WHO pain ladder to a biopsychosocial approach, but high-quality evidence for the effectiveness of treatments and management options is limited.

Evidence is often limited by duration (frequently less than three- or six-month duration), limited indication, intervention used, ability to blind, outcome assessment, bias and small numbers of participants, variation between individuals and multiple presentations of chronic pain.

We have provided an indication on the strength of recommendations and guidance, which indicates the type of evidence that the recommendation is based on. The categories follow SIGN guidance terminology, categorising recommendations as strong, conditional or a good practice point.

This guide builds upon the previous 2018 strategy and has been written by Scottish Government and NHS Scotland, supported by individuals with lived experience, patient organisations and the multidisciplinary team across primary and secondary care.

This guide promotes the importance of good communication between individuals living with chronic pain and the clinician, to enable an understanding of ‘what matters to them’ in line with the 7-Steps medication review process. The guide acknowledges that chronic pain can make communication challenging and often time is required to establish a therapeutic relationship. However, there are benefits to the individual, and clinician, with less reliance on medication, greater empowerment and improved quality of life. These are highlighted throughout the guide with examples, from individuals with lived experience and clinicians, demonstrating that a change in practice is possible and rewarding.

There are a large range of resources available to support the management of chronic pain, and these are included throughout the guide and collated in a separate resource section. These resources have been identified by the experts who wrote each section.

Though this guide focusses on chronic pain, it should be viewed in the context that most individuals with chronic pain may have additional long-term conditions as well and may be living with multiple long-term conditions. Clinicians should consider this document together with the recommendations in Polypharmacy Guidance 2026. The advice is based on existing clinical guidance, in particular SIGN 173 - Management of Chronic Pain, which should be considered a companion document to this.

We are extremely grateful to all those who contributed to the working group, the review and development of this guide.

Prof. Alpana Mair
Head of Effective
Prescribing and Therapeutics

Prof. Sir Gregor Smith
Chief Medical Officer

Prof. Alison Strath Prof.
Chief Pharmaceutical Officer

Aisha Holloway
Chief Nursing Officer