Chronic Non-Malignant Pain

First Line

Second Line

Specialist

Hospital Only

Pain lasting longer than 3 months duration is defined as chronic.

Guidance on acute pain (pain lasting less than 3 months duration) can be found here.

Chronic pain sometimes begins with an acute injury but the pain does not resolve as expected; often it is not clear how a chronic pain has started. Common types of chronic pain include low back pain (refer to management of low back pain and sciatica), pain related to arthritis and pain related to injury to a nerve or other part of the nervous system (refer to management of neuropathic pain). Pain can range from mild or severe.

Chronic pain can cause low mood, irritability, poor sleep and mobility impairment. Unlike acute pain, chronic pain is difficult to treat with most types of treatment helping less than a third of patients. Most treatments aim to help patients self-manage their pain and improve function in a number of domains. Different treatments work for different patients.

Medicines generally and opioids in particular are often not very effective for chronic pain and are usually a small part of the pain management plan (see below). Other non-drug treatments may be used including advice about activity and increasing physical fitness, and psychological therapies such as Cognitive Behavioural Therapy (CBT) and meditation techniques such as mindfulness. When medicines are prescribed they should be used in combination with other treatment approaches to support improved physical, psychological and social functioning. See pharmacological treatment of chronic non-malignant pain below.

Helping a patient understand about chronic pain is important and in particular helping him or her understand that physical activity does not usually cause further tissue damage and is therefore safe. Patients may be directed to the Torbay and South Devon NHS Foundation Trust pain service resource: ReConnect2Life, an interactive programme to aid patients understanding of their pain.

Fibromyalgia is a long-term condition that causes pain all over the body. See here for further guidance in West Devon and here for further guidance in South Devon.

Cancer pain is usually described separately and may be short or long lasting. The pain can relate to the cancer itself or the cancer treatment. Cancer pain is usually associated with an obvious source of tissue damage and may be acute or chronic. Neuropathic pain occurs in relation to cancer diagnoses and treatments (such as radiotherapy). Because cancer pain treatment, particularly at the end of life, is often for a short duration, it is usually more successful than chronic pain treatment. Patients who recover from cancer or who survive a long time with cancer may have pain that is more difficult to treat. Additionally, patients with cancer may experience acute or chronic pain unrelated to their cancer. Refer to 16.2 Treatment of pain in palliative care.

Opioids

A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation).
Opioids can have serious consequences when they are not providing sufficient benefit or being taken in a manner that was not intended.
Initial prescribing of opioid medicines for pain should be considered as a trial period, with outcomes of treatment agreed with the patient.
Baseline pain level should be assessed and documented prior to commencing patients on opioids, in order to assess the level of benefit of treatment. Patients should not expect total resolution of pain; a 3 – 5 point reduction in pain score (on a scale of 0 to 10) would be considered reasonable. An example pain rating scale may be downloaded from the British Pain Society website here.
Patients who do not gain pain relief (3 - 5 point reduction) from an agreed dose of opioid within 2-4 weeks should have that drug withdrawn as they are unlikely to gain benefit in the long term. Patients who may benefit from opioids in the long term will demonstrate a favourable response within 2-4 weeks, although short-term efficacy does not guarantee long-term efficacy.
If at the end of the trial, agreed outcomes have not been achieved or progress made towards them, then the patient and prescriber need to discuss whether to continue treatment.
It is recommended that if a patient is using opioids but is still in pain, the opioids are not effective and should be discontinued, even if no other treatment is available. When medicines don't give sufficient analgesia there is a risk of dose escalation, which is rarely helpful.
There is no good evidence of dose-response with opioids, beyond doses used in clinical trials (usually up to 120mg/day morphine equivalent) but the risk of harm increases substantially. There is no evidence for efficacy of high dose opioids in long-term pain.
Data regarding improvement in quality of life with long-term opioid use are inconclusive.
It is important to review the risks and benefits of continued opioid therapy on a regular basis.
It may be appropriate for a specialist to supervise treatment. Consider a written contract for initiation (see Management of Opioids).
MHRA Drug Safety Update (September 2020): Opioids: risk of dependence and addiction
- Before prescribing opioids, discuss with the patient the risks and features of tolerance, dependence, and addiction, and agree together a treatment strategy and plan for end of treatment
- The formulary has additional guidance supporting the recommendations from this review (See Management of Opioids)

See also section on pharmacological treatment of chronic non-malignant pain below and Management of Opioids page.

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Key points:

Medications are usually a small part of the pain management plan and should be used in conjunction with non-pharmacological interventions such as advice regarding activity, physiotherapy and an explanation that pain may be resistant to medication and complete relief of symptoms is not a goal of therapy.
Regardless of pain intensity, it is rational to start with non-opioid drugs, where these have some demonstrated efficacy for the condition being treated.
Trials of both weak and strong opioid therapy may be considered for some patients with well-defined pain diagnoses in whom symptoms persist despite first line interventions. All drugs prescribed for pain should be subject to regular review to evaluate continued efficacy, and periodic dose tapering is necessary to evaluate on-going need for treatment.
Ensure compliance is good before dose increase (e.g. paracetamol is being taken at optimal dose, opioids are being taken at prescribed dose).
The oral route is to be preferred over all other routes.
Multi-agent (i.e. NSAID/non-opioid) analgesia is more effective than a single agent alone.
Baseline pain level should be assessed and documented prior to commencing patients on opioids, in order to assess the level of benefit of treatment. Patients should not expect total resolution of pain; a 3 – 5 point reduction in pain score (on a scale of 0 to 10) would be considered reasonable. An example pain rating scale may be downloaded from the British Pain Society website.
If analgesia fails, consider neuropathic pain

Step 1

Regular Paracetamol 1g six hourly (or appropriate lower dose)

See section 4.7.1 Non-opioid analgesics and compound analgesic preparations

Stop and review before moving to step 2.

Step 2

Add in NSAID such as ibuprofen (maximum 400mg eight hourly) or naproxen (maximum 500mg 12 hourly) unless contraindicated. Consider gastro-protection; stop if not effective (see notes above).

See section 10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)

Notes

Only prescribe an NSAID if the benefits of treatment clearly outweigh the risks and a need for an anti-inflammatory agent is identified. Avoid long term use if possible; refer to Prescribing non-steroidal anti-inflammatory drugs
If an NSAID is used for analgesia alone, it is recommended that the drug should be changed if no response is obtained after 1 week. If an anti-inflammatory action is required, then a trial of 3 weeks should be allowed
Review regularly.

Stop and review before moving to step 3.

Step 3

Co-codamol 8/500 two tablets six hourly when required, or
Co-dydramol 10/500 two tablets six hourly when required, or
Co-codamol 30/500 two tablets six hourly when required.

See section 4.7.1 Non-opioid analgesics and compound analgesic preparations

Notes

There may be advantages to prescribing an opioid and non-opioid separately; consideration should be given to the increased tablet burden on an individual patient basis. Prescribing medication separately gives flexibility in both the adjustment of the doses and in the selection of the most appropriate combination.
Caution using codeine where eGFR less than 30mL/min.
Review regularly: Prescribe one drug at a time in step 2 to achieve effective analgesia, stepping up as necessary.
Following national guidance from NHS England, co-proxamol is not recommended for use due to significant safety concerns. Click here for more information.
Consider other pharmacological agents; assess character of pain - if neuropathic follow guidance on Neuropathic pain

Stop and review before moving to step 4.

Step 4

Zomorph (morphine sulphate) 10mg 12 hourly as starting dose. For patients who cannot swallow Zomorph capsules, their contents can be administered directly in semi-solid food (puree, jam, yoghurt)
Sevodyne (buprenorphine) patches: only in patients with cognitive deficit, or with swallowing difficulties and after a trial of soluble/liquid medication. Remember Zomorph capsules can be opened up for ease of swallowing.

See section 4.7.2 Opioid analgesics

Notes

Generally, use modified release opioids on a regular basis. There is not usually a basis for giving immediate release or breakthrough opioid analgesia.
Morphine oral solution 10mg/5ml is to be avoided in chronic non-malignant pain.
Set maximum dose (e.g. Zomorph 40mg 12 hourly) and treatment period (e.g. one month)
Baseline pain level should be assessed and documented prior to commencing patients on opioids, in order to assess the level of benefit of treatment. Patients should not expect total resolution of pain; a 3 – 5 point reduction in pain score (on a scale of 0 to 10) would be considered reasonable. An example pain rating scale may be downloaded from the British Pain Society website here.
Assess abuse potential.
Caution using morphine where eGFR less than 30mL/min. Use oxycodone instead of morphine for patients with renal impairment (eGFR less than 30mL/min).

Review regularly:

If the initial dose of an opioid was effective but becomes ineffective, this may be due to tolerance. Consider withdrawing treatment for 2-3 weeks and then reintroducing a small dose of immediate release opioid, to see if the patient has regained opioid sensitivity. The opioid should be used intermittently to avoid recurrence of tolerance. Although there is no formal definition of what "intermittent use" is, it has been suggested that greater than 10 analgesic use days per month increases the likelihood of medication overuse headaches. Also try to avoid promoting daily use.
Do not use fentanyl (any preparation) for non-cancer pain
Methadone should only be used for pain when initiated by the pain clinic or palliative care team. In exceptional circumstances, and with ongoing input from the pain clinic or palliative care team, treatment may be continued in primary care
Buprenorphine sublingual tablets are not recommended for prescribing in primary care for the management of pain. For their use as an adjunct in the treatment of opioid dependence, refer to section 4.10.3 Opioid dependence
Injectable opioids should not be used in the management of patients with persistent non-cancer pain
Avoid immediate release strong opioids in chronic pain.

Step 5 - Pain Clinic Management

Failure to achieve adequate analgesia, concerns about excessive or uncontrolled opioid use (or rapid escalation) or reaching an agreed target dose should trigger referral to a pain management specialist (suggest 120mg morphine equivalent per 24 hours)
Problem drug use should trigger referral to a Substance Misuse specialist.

Formulary