GPAtlas🧭 When to suspect
Pain is defined as chronic once it has persisted for more than 3 months. The first clinical task is to decide which kind of chronic pain you are dealing with, because the drug approach differs completely: chronic primary pain (pain that is the condition itself and is not explained by another diagnosis, such as fibromyalgia or chronic primary musculoskeletal pain), chronic secondary pain (a symptom of an underlying condition, e.g. osteoarthritis or endometriosis), and neuropathic pain (arising from nerve damage or disease).
The second, equally important task is to proactively review every patient taking, or being considered for, a dependence-forming medicine – opioids, gabapentinoids, benzodiazepines or Z-drugs. The aim of review is to re-weigh benefit against harm, anchored on function and quality of life rather than the pain score. For chronic primary pain in particular, the counter-intuitive headline is that almost no analgesic class helps in the long term, and several cause significant harm.
| Type of chronic pain | What it is | Drug approach |
|---|---|---|
| Chronic primary pain | Pain > 3 months not explained by another condition (e.g. fibromyalgia) | Consider an antidepressant only; do not start opioids, NSAIDs, paracetamol, gabapentinoids or benzodiazepines |
| Chronic secondary pain | Pain from an underlying diagnosis (e.g. osteoarthritis, endometriosis) | Treat the underlying condition using its own guideline |
| Neuropathic pain | Pain from nerve damage or disease (e.g. diabetic neuropathy, post-herpetic) | Amitriptyline, duloxetine, gabapentin or pregabalin (first-line) |
Source: NICE NG193 · NICE CG173 · Faculty of Pain Medicine (Opioids Aware)
🔒 Sign up free to read the full topic
You're viewing a free preview. Create a free account to unlock the rest.
Sign up free →Sample topics are open to everyone in the Free Sample Bundle.