Chronic Pain & Opioid Dependence

🔍 When to Suspect

Pain that has lasted for more than 3 months, persisting beyond the expected healing time and significantly impacting the patient's daily life, mood, and function

From the full topic in The Ocean Library: Chronic Pain & Opioid Dependence

🧭 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)

---