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Chronic Non-Malignant Pain
Pain lasting longer than 3 months duration is defined as chronic.
Guidance on acute pain can be found here.
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).
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. 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.
Fibromyalgia is a long-term condition that causes pain all over the body. Analgesia such as paracetamol may be helpful for the management of pain in fibromyalgia, however there is little evidence that strong opiates (such as morphine or tramadol) work particularly well, and these should be avoided for long term pain management. North Devon District Hospital (Royal Devon University Healthcare NHS Foundation Trust) offers further information on the condition here. For referral guidance in North Devon, click here; and for referral guidance in East Devon, click here.
Cancer pain may be acute or chronic. The pain can relate to the cancer itself or the cancer treatment. Neuropathic pain occurs in relation to cancer diagnoses and treatments (such as radiotherapy). Patients who recover from cancer or who survive a long time with cancer may have pain that is more difficult to treat. Refer to section 16.2 Pain control 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 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; local versions may also be available and obtained from the Pain Teams.
- 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. Short-term efficacy does not guarantee long-term efficacy.
- There is no good evidence of dose-response with opioids beyond 120mg/day morphine or equivalent but the risk of harm increases substantially. There is no evidence for efficacy of high dose opioids in long-term pain.
- It is important to review the risks and benefits of continued opioid therapy on a regular basis. Management of Opioids
- It may be appropriate for a specialist to supervise opioid treatment, particularly patients with a history of substance misuse or if the pain is potentially problematic. Consider a written contract for initiation.
- When treatment with opioids exceeds 3 days, a laxative should be considered (see management of constipation in adults, opioid induced constipation and section 1.6 laxatives).
- 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 Management of Opioids and section 4.7.2 Opioid analgesics
A stepwise approach to chronic non-malignant pain management in adults has been included below for guidance however the complexity of the person's individual needs, preferences for treatments, health priorities and lifestyle, must be considered.
Medications should be prescribed 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.
Remember:
- 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.
- 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.
If neuropathic pain is suspected, a stepwise approach to management is not appropriate and anti-neuropathic medication should be used. See here for guidance.
Consider an early referral if starting strong opioids, especially if the pain presentation is/potentially is problematic.
Step 1
- Regular paracetamol 1g six hourly (or appropriate lower dose); maximum 4 g per day
See section 4.7.1 Non-opioid analgesics and compound analgesic preparations
Stop and review before moving to step 2.
Step 2
- Continue paracetamol as above, and add in NSAID such as ibuprofen (maximum 400mg TDS) or naproxen (maximum 500mg 12 hourly) unless contraindicated.
- When prescribing NSAIDs use the lowest effective dose for the shortest duration necessary to control symptoms. Stop treatment if not effective
- Consider gastro-protection alongside NSAID.
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
- Continue paracetamol and NSAID as above, and add codeine 15mg, 30mg, or 60mg prescribed separately for administration every 4–6 hours (maximum total daily dose of codeine: 240mg) OR
- Co-codamol 30mg/500mg may be considered an option for patients taking regular high dose paracetamol and codeine prescribed separately; 1–2 tablets every 4–6 hours, maximum 8 tablets daily (use co-codamol cautiously in opiate naïve patients)
See sections 4.7.1 Non-opioid analgesics and compound analgesic preparations and 4.7.2 Opioid analgesics
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
- The capacity to metabolise codeine to morphine can vary considerably between individuals; there is a marked increase in morphine toxicity in patients who are ultra-rapid codeine metabolisers, and a reduced therapeutic effect in poor codeine metabolisers. Prescribers should counsel patients on the symptoms of opioid toxicity prior to prescribing codeine and review patients shortly after initiating treatment. If no beneficial analgesic effect, treatment should be discontinued and alternative options discussed with the patient.
- Caution using codeine where eGFR less than 30mL/min
- Review regularly
- 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
- Continue paracetamol and NSAID. Zomorph (morphine sulphate) 10mg every 12 hours may be prescribed as a starting dose. Discontinue codeine.
- For patients who cannot swallow Zomorph capsules, their contents can be administered directly in semi-solid food (puree, jam, yoghurt) – see Summary of Product Characteristics (SmPC) for further details.
- Sevodyne (buprenorphine) patches should be reserved for use 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
- Opioids should be prescribed mainly as controlled release formulations
- Breakthrough doses of 1/6th of the total daily dose of controlled release opioid, may be prescribed as immediate release morphine every 4 hours when required
- 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.
- Assess abuse potential
- Use oral oxycodone instead of oral morphine for patients with renal impairment (eGFR less than 30mL/min), or in patients intolerant to morphine. Fentanyl patches may be considered in the management of severe chronic pain in patients with renal failure, morphine intolerance or poor compliance such as due to swallowing difficulties
- 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
- 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 "intermittent use", it has been suggested that greater than 10 analgesic use days per month increases the likelihood of medication overuse headaches. Avoid promoting daily use. If opioid rotation/switching is required as a result of opioid tolerance please refer to guidance here
- Consider an early referral if starting strong opioids, especially if the pain presentation is/potentially is problematic.
Step 5 - Pain Clinic Management
- Failure to achieve adequate analgesia, or concerns about excessive or uncontrolled opioid use (or rapid escalation) should trigger prompt referral to a pain management specialist.
- Problem drug use should trigger referral to a Substance Misuse specialist.
