GPAtlas🧭 When to suspect
Pain is an unpleasant sensory and emotional experience shaped by biological, psychological and social factors. A person's self-report is the cornerstone of assessment and should always be respected – gauge severity with a validated pain scale (for example 1–10) alongside the history and examination.
Characterise the pain by duration – acute (less than 4 weeks), subacute (4–12 weeks), chronic (more than 3 months) or acute-on-chronic (a flare). Then determine the mechanism, because this drives the choice of analgesic. Management follows a stepwise analgesic ladder (based on WHO principles) adapted for primary care, with distinct pathways for children (under 16) and adults (16 and over).
| Pain mechanism | What it means & analgesic relevance |
|---|---|
| Nociceptive | Tissue damage (e.g. trauma, surgery). Typically responds well to paracetamol and NSAIDs. |
| Inflammatory | Immune-mediated (e.g. arthritis, soft-tissue injury). NSAIDs are particularly useful where not contraindicated. |
| Neuropathic | Nerve damage or dysfunction. Often poorly responsive to simple analgesia – consider neuropathic-specific agents rather than escalating the ladder. |
| Nociplastic | Altered pain perception without clear tissue damage (e.g. fibromyalgia, chronic primary pain). Escalating analgesia – especially opioids – rarely helps. |
|
⚠️ Common pitfall Climbing the analgesic ladder for chronic primary (nociplastic) pain – fibromyalgia, mechanical low back pain, non-specific widespread pain. Opioids and repeated dose escalation give little durable benefit here and risk dependence and harm; the evidence favours exercise, psychological therapy and self-management. Recognising the pain mechanism early prevents an unhelpful and hard-to-reverse opioid trajectory. |
Source: WHO analgesic ladder · British Pain Society · NICE NG193
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