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

4. Summary of recommendations

4.1 General

• Utilise a person-centred approach to the management of chronic pain
• Non-pharmacological approaches should be considered as the first step to support the management of chronic pain
• The management of chronic pain may require time to develop a therapeutic relationship with the individual who has chronic pain
• Utilise a person-centred biopsychosocial approach which includes the context of their background, beliefs, fears, expectations; previous experiences of pain; causes and its treatment and other aspects of their physical and mental health
• Ensure good communication between clinician and the individual, and between areas of care, e.g. post-surgery to GP practice

Management of acute pain (outwith this guidance), especially post-surgery is important as may influence the transition from acute to chronic pain

4.2 Communication

• Although evidence is limited in this area, practitioner experience shows that good communication positively impacts the experience of the individual with chronic pain and builds trust
• Acknowledge that chronic pain is a long-term condition
• Acknowledge that people will be at different stages of their chronic pain journey and utilise various tools available to support effective communication

4.3 Non-pharmacological approaches

• High quality evidence for individual non-pharmacological approaches is limited, due to the challenge of blinding interventions, variation between individuals and multiple presentations of chronic pain. There are many good practice interventions that may provide benefit based on practitioner and individual experience, and limited evidence
• Explore people’s preferences and choices for self-management
• Clinicians should offer non-pharmacological resources and services to develop a personalised plan, which may include pharmacological management
• Non-pharmacological approaches include:
  • Effective communication (see chapter seven)
  • Support empowerment and self-management through understanding of pain and acceptance
  • Physical activity should be advised as a recommended treatment for people living with chronic pain
  • Discuss possible activity interventions and support those with chronic pain to help choose suitable activities which are based on the person’s needs and capabilities
  • Acknowledge and discuss thoughts and emotions and their impact on pain
  • Tailor management of stress to individual needs and preferences
  • Consider using relaxation techniques
  • Consider CBT for insomnia as an effective management strategy
  • Psychological therapies (cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT) should be considered. These should be delivered by appropriately trained professionals
  • Support person-centred goals in management of chronic pain which are specific, measurable, achievable, realistic and timed (SMART)
  • Consider providing sleep hygiene advice and reminding individuals that changes in sleep habits can take time to develop
  • Consider provide advice on healthy eating and hydration.
  • Consider offering mindfulness based approaches to manage pain for individuals who express a preference for this

4.4 Pharmacological management

• In chronic pain efficacy is considered as a 30-50% reduction in pain intensity (dependent on trial evidence), not elimination of pain. This should be discussed at initiation of treatment
• Ensure individuals are aware of the risks of dependency with opioids, gabapentinoids and antidepressants on initiation and support withdrawal of these as appropriate
• A holistic approach should be taken to manage pain, using the 7-Step medication review process, assessing the indication, impact of medicines on not only pain levels, but also the risks and benefits, including the effect on physical function, mental health and emotional factors (e.g. mood, anxiety, sleep, social and sexual function)
• Non-steroidal anti-inflammatory drugs (NSAID):
  • Recommend using for shortest time and at lowest dose due to adverse effects
• Opioids:
  • Be aware there are few trials of efficacy of long-term opioid use (≥three months) in individuals with chronic non-malignant pain, particularly at doses over 50mg morphine equivalent dose (MED), per day
  • All people receiving opioid doses of >50mg MED/day should be reviewed regularly (at least annually) to detect emerging harms and consider ongoing effectiveness
  • Pain specialist advice or review should be sought at doses >90mg MED/day
  • Inform individuals of risk of short-term and long-term harms
  • Review efficacy and adverse effects within four weeks of starting opioid treatment or sooner if required
  • Clinicians should consider prescribing naloxone for those prescribed an opioid and who may be at risk of an opioid overdose
• Antidepressants:
  • Be aware there is limited evidence for many indications
  • Ensure review after four weeks and discontinue if no improvement in pain relief, physical function or subjective improvement
• Anticonvulsants:
  • Consider renal function (creatinine clearance) regarding maximum dosage
  • Inform of significant risk of adverse effects with gabapentinoids, including drowsiness, dizziness, nausea, weight changes (abnormal appetite), cognition, speech problems and ataxia
  • Risk of respiratory depression and foetal abnormalities
• Other analgesics:
  • Consider those identified as having low and limited clinical evidence and review use – nefopam, lidocaine plasters, methocarbamol

4.5 Opioid management

• Consider reduction of opioids as there is little evidence that they are helpful for long-term pain but have many side effects and known long-term harms
• Explain the importance of reducing opioids to the individual, develop a tapering plan in agreement with the individual, providing chronic pain education if necessary
• Support the individual during the reduction, considering emotional impact and adverse effects using the available tools
• In secondary care, consider opioid stewardship especially before, during and after surgery, ensuring good communication between secondary care and primary care