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4.7.2 Chronic non-malignant pain

General Prescribing Notes

  • Refer to NICE NG193 Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain.
  • Chronic pain persists for more than 3 months.
  • There has been a move away from the use of medication to treat chronic pain. Its primary purpose should be to facilitate patients to improve functional activity and to engage in pain management strategies / programmes, not to relieve pain.
  • Managing the psychological and social aspects of pain is important. Coping strategies and other useful information can be found within the online resources highlighted below.
  • Consider signposting/referral to:
    • Physical Activity Referral Scheme (PARS). GP practices and other relevant HSC staff can refer using PARS specific protocols generated through CCG.
    • Relevant support groups e.g. Versus Arthritis (VA) NI provides face to face, telephone and virtual support and pain management courses.
    • Better Days Pain Support Programmes run by Healthy Living Centres (HLC). Some centres provide pain support programmes. Refer to the HLC website or contact your local HLC to find out about the services they offer.
    • Online resources such as My live well with Pain and Flippin Pain and MyNI pain management.
    • Access additional services, e.g. Specialist Pain Clinic.
    • Relevant specialist before increasing dose above 90mg morphine equivalent.

Note: all opioids recommended by specialists should be accompanied by a clear management plan including arrangements for review, which has also been discussed with the patient.

Management of Chronic Primary Pain

  • Chronic primary pain has no clear underlying condition or is out of proportion to any observable injury or illness e.g. fibromyalgia.
  • Recommended management options are mainly non-pharmacological – see NICE NG193.
  • Antidepressants (amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline) can be considered even in the absence of depression. Note this is off-label use.
  • Do not initiate opioids, NSAIDs, paracetamol, antiepileptic drugs (including gabapentinoids), antipsychotics, benzodiazepines, local anaesthetics, corticosteroid +/- local anaesthetic trigger point injections or ketamine.

Management of Chronic Secondary Pain

  • Chronic secondary pain is a symptom of an underlying condition and should be managed in line with the relevant NICE guideline for the underlying condition e.g. low back pain and sciatica  or osteoarthritis. Neuropathic pain is covered here
  • Chronic secondary pain and chronic primary pain can co-exist and clinical judgement should be used to determine if it would also be helpful to manage as chronic primary pain alongside the management of the disease itself.
  • In chronic secondary pain opioids have a very limited role. They should only be used where absolutely necessary and only where recommended as an option within the specific NICE guidance for the condition. In these circumstances only, please refer to formulary choices and prescribing notes below:
1st choiceNon-pharmacological management
Paracetamol tablets 500mg

Plus/Or NSAID see 10.1.1

2nd choice

Consider addition of codeine 15mg tablets prescribed separately to paracetamol

Lowest dose that achieves goals. Max duration of codeine treatment 8-12 weeks

2nd choice
(alternative option to prescribing codeine separately)
Co-codamol 8/500 tablets (codeine 8mg with paracetamol 500mg)
Co-codamol 15/500 tablets (codeine 15mg with paracetamol 500mg)

Co-codamol 30/500 tablets (codeine 30mg with paracetamol 500mg)

Lowest dose that achieves goals. Max duration of codeine treatment 8-12 weeks

Prescribing Notes

  • Set goals with the patient before starting any medication. The primary aim of treatment should be to improve function and quality of life. Pain reduction of 30% and a positive impact on daily life is a realistic goal (not 100% pain relief).
  • Before starting opioids refer to NICE NG215 for information that should be considered and discussed with the patient, including steps to reduce the risk of dependence.
  • In chronic non-malignant pain the long-term use of opioids has many implications. See Faculty of Pain Medicine website for resources to support patients and healthcare professionals and the NI Formulary Patient Area.
  • Oral morphine /codeine equivalence should be considered to ensure the dosage is safe and appropriate
  • Opioids have the potential to impair driving and anyone who is adversely affected must not drive. If a patient has a condition or is undergoing treatment that could impair their fitness to drive, healthcare professionals should advise them on their legal requirement to notify the DVA.  Discuss with the patient and document – for further details see driving information in the Opioid Prescribing for Chronic Pain Resource Pack.


  • Some patients may be at increased risk of experiencing toxicity at therapeutic doses of paracetamol, particularly those with a body-weight under 50 kg and those with risk factors for hepatotoxicity. Clinical judgement should be used to adjust the dose of oral and intravenous paracetamol in these patients.
  • Long term use of opioids in non-cancer pain (longer than 3 months) carries an increased risk of dependence and addiction. Risks should be discussed with patient before prescribing – see MHRA recommendations.
  • The use of opioids should be reviewed regularly, preferably face to face and with the same clinician; this should be at least monthly in the first six months after stable dosing has been achieved. Frequency of review thereafter can be clinically determined by the complexity of the case, but should be at least biannually. NICE have produced a visual summary for reviewing medication associated with dependence.
  • Patients must be aware of the signs and symptoms of opioid sensitivity/toxicity – i.e. trouble breathing, tiredness, extreme sleepiness, inability to think, walk, or talk normally and feeling faint, dizzy, or confused. If toxicity is suspected advise patients to seek medical attention immediately.
  • Older patients are particularly susceptible to respiratory depression and constipation secondary to opioids.
  • Never prescribe more than one opioid long-term e.g. codeine and tramadol.
  • Where possible, avoid co-prescribing other CNS depressants e.g. benzodiazepines or gabapentinoids with opioids. If co-prescribing cannot be avoided, exercise extreme caution due to the increased risk of serious side effects e.g. respiratory depression. See MHRA
  • Patients taking enzyme inducing or inhibiting medicines may demonstrate an altered response to some opioid medications and doses may need to be adjusted – refer to BNF for information on specific drug combinations.