Chronic Pain (Primary and Secondary) in Over 16s: Assessment and Management

Overview 

Chronic pain, sometimes known as long-term pain or persistent pain, is pain that lasts for more than 3 months. This Guidelines summary aims to assist primary healthcare professionals to diagnose and manage chronic pain, including chronic primary pain, chronic secondary pain, or both, in people aged 16 years and over.

This guideline covers assessment of all chronic pain and management of chronic primary pain.

Read the related Guidelines in Practice article: Adopt a Holistic Approach to the Management of Chronic Pain.

Visual Summary

Algorithm 1: Chronic Pain (Primary and Secondary)—Using NICE Guidelines for Assessment and Management

Assessing All Types of Chronic Pain

Person-centred Assessment

• Offer a person-centred assessment to those presenting with chronic pain (chronic primary pain, chronic secondary pain, or both), to identify factors contributing to the pain and how the pain affects the person’s life
• When assessing and managing any type of chronic pain (chronic primary pain, chronic secondary pain, or both) follow the recommendations in the NICE guideline on patient experience in adult NHS services, particularly relating to:
  • knowing the patient as an individual
  • enabling patients to actively participate in their care, including:
    • communication
    • information
    • shared decision-making
• Foster a collaborative and supportive relationship with the person with chronic pain.

Thinking About Possible Causes for Pain

• Think about a diagnosis of chronic primary pain if there is no clear underlying (secondary) cause or the pain or its impact is out of proportion to any observable injury or disease, particularly when the pain is causing significant distress and disability
• Make decisions about the search for any injury or disease that may be causing the pain, and about whether the pain or its impact are out of proportion to any identified injury or disease, using clinical judgement in discussion with the person with chronic pain
• Recognise that an initial diagnosis of chronic primary pain may change with time. Re-evaluate the diagnosis if the presentation changes
• Recognise that chronic primary pain can coexist with chronic secondary pain.

Talking About Pain—How This Affects Life and How Life Affects Pain

• Ask the person to describe how chronic pain affects their life, and that of their family, carers, and significant others, and how aspects of their life may affect their chronic pain. This might include:
  • lifestyle and day-to-day activities, including work and sleep disturbance
  • physical and psychological wellbeing
  • stressful life events, including previous or current physical or emotional trauma
  • current or past history of substance misuse
  • social interaction and relationships
  • difficulties with employment, housing, income, and other social concerns
• Be sensitive to the person’s socioeconomic, cultural and ethnic background, and faith group, and think about how these might influence their symptoms, understanding, and choice of management
• Explore a person’s strengths as well as the impact of pain on their life. This might include talking about:
  • their views on living well
  • the skills they have for managing their pain
  • what helps when their pain is difficult to control
• Ask the person about their understanding of their condition, and that of their family, carers, and significant others. This might include:
  • their understanding of the causes of their pain
  • their expectations of what might happen in the future in relation to their pain
  • their understanding of the outcome of possible treatments
• When assessing chronic pain in people aged 16–25, take into account:
  • any age-related differences in presentation of symptoms
  • the impact of the pain on family interactions and dynamics
  • the impact of the pain on education and social and emotional development
  • see the NICE guideline on Transition from children’s to adult’s services for young people using health or social care services
• Recognise that living with pain can be distressing and acknowledge this with the person with chronic pain.

Providing Advice and Information

• Provide advice and information relevant to the person’s individual preferences, at all stages of care, to help them make decisions about managing their condition, including self-management
• Discuss with the person with chronic pain and their family or carers (as appropriate):
  • the likelihood that symptoms will fluctuate over time and that they may have flare-ups
  • the possibility that a reason for the pain (or flare-up) may not be identified
  • the possibility that the pain may not improve or may get worse and may need ongoing management
  • there can be improvements in quality of life even if the pain remains unchanged
• When communicating normal or negative test results, be sensitive to the risk of invalidating the person’s experience of chronic pain.

Developing a Care and Support Plan

• Discuss a care and support plan with the person with chronic pain. Explore in the discussions:
  • their priorities, abilities, and goals
  • what they are already doing that is helpful
  • their preferred approach to treatment and balance of treatments for multiple conditions
  • any support needed for young adults (aged 16–25) to continue with their education or training, if this is appropriate
• Explain the evidence for possible benefits, risks, and uncertainties of all management options when first developing the care and support plan and at all stages of care
• Use these discussions to inform and agree the care and support plan with the person with chronic pain and their family or carers (as appropriate)
• Offer management options:
  • in line with the Managing chronic primary pain section of this summary, if the assessment suggests the person has chronic primary pain
  • in line with the NICE pathway on chronic pain if the underlying condition adequately accounts for the pain and its impact
• When chronic primary pain and chronic secondary pain coexist, use clinical judgement to inform shared decision-making about management options in the Managing chronic primary pain section of this summary and in the NICE guideline for the chronic pain condition.

Flare-ups

• Offer a reassessment if a person presents with a change in symptoms such as a flare-up of chronic pain. Be aware that a cause for the flare-up may not be identified
• If a person has a flare-up of chronic pain:
  • review the care and support plan
  • consider investigating and managing any new symptoms
  • discuss what might have contributed to the flare-up.

Managing Chronic Primary Pain

This section covers managing chronic primary pain (in which no underlying condition adequately accounts for the pain or its impact). Chronic primary pain and chronic secondary pain can coexist.

Non-pharmacological Management of Chronic Primary Pain

Exercise Programmes and Physical Activity for Chronic Primary Pain

• Offer a supervised group exercise programme to people aged 16 and over to manage chronic primary pain. Take people’s specific needs, preferences, and abilities into account
• Encourage people with chronic primary pain to remain physically active for longer-term general health benefits. See NICE guidelines on Physical activity and behaviour change: individual approaches.

Psychological Therapy for Chronic Primary Pain

• Consider acceptance and commitment therapy or cognitive behavioural therapy for pain for people aged 16 and over with chronic primary pain, delivered by healthcare professionals with appropriate training
• Do not offer biofeedback to people aged 16 and over to manage chronic primary pain.

Acupuncture for Chronic Primary Pain

• Consider a single course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system, for people aged 16 and over to manage chronic primary pain, but only if the course:
  • is delivered in a community setting and
  • is delivered by a band 7 (equivalent or lower) healthcare professional with appropriate training and
  • is made up of no more than 5 hours of healthcare professional time or
  • is delivered by another healthcare professional with appropriate training and/or in another setting for equivalent or lower cost.

Electrical Physical Modalities for Chronic Primary Pain

• Do not offer any of the following to people aged 16 and over to manage chronic primary pain because there is no evidence of benefit:
  • transcutaneous electrical nerve stimulation
  • ultrasound
  • interferential therapy.

Pharmacological Management of Chronic Primary Pain

• Consider an antidepressant—either amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine, or sertraline—for people aged 18 and over to manage chronic primary pain, after a full discussion of the benefits and harms^[A]
• Seek specialist advice if pharmacological management with antidepressants is being considered for young people aged 16–17
• If an antidepressant is offered to manage chronic primary pain, explain that this is because these medicines may help with quality of life, pain, sleep, and psychological distress, even in the absence of a diagnosis of depression
• Do not initiate any of the following medicines to manage chronic primary pain in people aged 16 and over:
  • antiepileptic drugs including gabapentinoids^[B]
  • antipsychotic drugs
  • benzodiazepines
  • corticosteroid trigger point injections
  • ketamine
  • local anaesthetics (topical or intravenous)
  • local anaesthetic/corticosteroid combination trigger point injections
  • non-steroidal anti-inflammatory drugs
  • opioids
  • paracetamol
• If a person with chronic primary pain is already taking any of the medicines in the recommendation above, review the prescribing as part of shared decision-making:
  • explain the lack of evidence for these medicines for chronic primary pain and
  • agree a shared plan for continuing safely if they report benefit at a safe dose and few harms or
  • explain the risks of continuing if they report little benefit or significant harm, and encourage and support them to reduce and stop the medicine if possible
• When making shared decisions about whether to stop antidepressants,^[A] opioids, gabapentinoids,^[B] or benzodiazepines, discuss with the person any problems associated with withdrawal
• For recommendations on stopping or reducing antidepressants, see the NICE guideline on Depression in adults
• For recommendations on reviewing treatments, see the NICE guidelines on Medicines optimisation and Medicines adherence
• For recommendations on cannabis-based medicinal products, including recommendations for research, see the NICE guideline on Cannabis-based medicinal products.

Footnotes

[A] In April 2021, this was an off-label use of these antidepressants. See NICE’s information on prescribing medicines

[B] Pregabalin and gabapentin (gabapentinoids) are Class C controlled substances (under the Misuse of Drugs Act 1971) and scheduled under the Misuse of Drugs Regulations 2001 as Schedule 3. Evaluate patients carefully for a history of drug misuse before prescribing and observe patients for development of signs of misuse and dependence (MHRA Drug Safety Update April 2019)