Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Assessing all types of chronic pain (chronic primary pain, chronic secondary pain, or both)

This section covers all types of chronic pain (pain that persists or recurs for more than 3 months). It includes chronic primary pain (in which no underlying condition adequately accounts for the pain or its impact) and chronic secondary pain (in which an underlying condition adequately accounts for the pain or its impact).

Chronic primary pain and chronic secondary pain can coexist.

These recommendations aim to inform a care and support plan by setting out a comprehensive person‑centred assessment of the causes and effects of pain and agreeing possible management strategies, including self‑management.

Person-centred assessment

1.1.1 Offer a person-centred assessment to those presenting with chronic pain (chronic primary pain, chronic secondary pain, or both), to identify factors contributing to the pain and how the pain affects the person's life.

1.1.2 When assessing and managing any type of chronic pain (chronic primary pain, chronic secondary pain, or both) follow the recommendations in the NICE guideline on patient experience in adult NHS services, particularly relating to:

  • knowing the patient as an individual

  • enabling patients to actively participate in their care, including:

    • communication

    • information

    • shared decision making.

1.1.3 Foster a collaborative and supportive relationship with the person with chronic pain.

Thinking about possible causes for pain

1.1.4 Think about a diagnosis of chronic primary pain if there is no clear underlying (secondary) cause or the pain or its impact is out of proportion to any observable injury or disease, particularly when the pain is causing significant distress and disability.

1.1.5 Make decisions about the search for any injury or disease that may be causing the pain, and about whether the pain or its impact are out of proportion to any identified injury or disease, using clinical judgement in discussion with the person with chronic pain.

1.1.6 Recognise that an initial diagnosis of chronic primary pain may change with time. Re-evaluate the diagnosis if the presentation changes.

1.1.7 Recognise that chronic primary pain can coexist with chronic secondary pain.

Talking about pain – how this affects life and how life affects pain

1.1.8 Ask the person to describe how chronic pain affects their life, and that of their family, carers and significant others, and how aspects of their life may affect their chronic pain. This might include:

  • lifestyle and day-to-day activities, including work and sleep disturbance

  • physical and psychological wellbeing

  • stressful life events, including previous or current physical or emotional trauma

  • current or past history of substance misuse

  • social interaction and relationships

  • difficulties with employment, housing, income and other social concerns.

1.1.9 Be sensitive to the person's socioeconomic, cultural and ethnic background, and faith group, and think about how these might influence their symptoms, understanding and choice of management.

1.1.10 Explore a person's strengths as well as the impact of pain on their life. This might include talking about:

  • their views on living well

  • the skills they have for managing their pain

  • what helps when their pain is difficult to control.

1.1.11 Ask the person about their understanding of their condition, and that of their family, carers and significant others. This might include:

  • their understanding of the causes of their pain

  • their expectations of what might happen in the future in relation to their pain

  • their understanding of the outcome of possible treatments.

1.1.12 When assessing chronic pain in people aged 16 to 25 years, take into account:

1.1.13 Recognise that living with pain can be distressing and acknowledge this with the person with chronic pain.

Providing advice and information

1.1.14 Provide advice and information relevant to the person's individual preferences, at all stages of care, to help them make decisions about managing their condition, including self-management.

1.1.15 Discuss with the person with chronic pain and their family or carers (as appropriate):

  • the likelihood that symptoms will fluctuate over time and that they may have flare-ups

  • the possibility that a reason for the pain (or flare-up) may not be identified

  • the possibility that the pain may not improve or may get worse and may need ongoing management

  • there can be improvements in quality of life even if the pain remains unchanged.

1.1.16 When communicating normal or negative test results, be sensitive to the risk of invalidating the person's experience of chronic pain.

Developing a care and support plan

1.1.17 Discuss a care and support plan with the person with chronic pain. Explore in the discussions:

  • their priorities, abilities and goals

  • what they are already doing that is helpful

  • their preferred approach to treatment and balance of treatments for multiple conditions

  • any support needed for young adults (aged 16 to 25) to continue with their education or training, if this is appropriate.

1.1.18 Explain the evidence for possible benefits, risks and uncertainties of all management options when first developing the care and support plan and at all stages of care.

1.1.19 Use these discussions to inform and agree the care and support plan with the person with chronic pain and their family or carers (as appropriate).

1.1.20 Offer management options:

  • in line with section 1.2 of this guideline if the assessment suggests the person has chronic primary pain

  • in line with the NICE guideline for the underlying chronic pain condition (see the NICE Pathway on chronic pain) if the underlying condition adequately accounts for the pain and its impact.

1.1.21 When chronic primary pain and chronic secondary pain coexist, use clinical judgement to inform shared decision making about management options in section 1.2 of this guideline and in the NICE guideline for the chronic pain condition.

Flare-ups

1.1.22 Offer a reassessment if a person presents with a change in symptoms such as a flare-up of chronic pain. Be aware that a cause for the flare-up may not be identified.

1.1.23 If a person has a flare-up of chronic pain:

  • review the care and support plan

  • consider investigating and managing any new symptoms

  • discuss what might have contributed to the flare-up (see recommendation 1.1.8 for influences on the experience of pain).

1.2 Managing chronic primary pain

This section covers managing chronic primary pain (in which no underlying condition adequately accounts for the pain or its impact). Chronic primary pain and chronic secondary pain can coexist.

Non-pharmacological management of chronic primary pain

Exercise programmes and physical activity for chronic primary pain

1.2.1 Offer a supervised group exercise programme to people aged 16 years and over to manage chronic primary pain. Take people's specific needs, preferences and abilities into account.

1.2.2 Encourage people with chronic primary pain to remain physically active for longer-term general health benefits (also see NICE guidelines on physical activity and behaviour change: individual approaches).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on exercise programmes and physical activity for chronic primary pain.

Full details of the evidence and the committee's discussion are in evidence review E: exercise for chronic primary pain.

Psychological therapy for chronic primary pain

1.2.3 Consider acceptance and commitment therapy (ACT) or cognitive behavioural therapy (CBT) for pain for people aged 16 years and over with chronic primary pain, delivered by healthcare professionals with appropriate training.

1.2.4 Do not offer biofeedback to people aged 16 years and over to manage chronic primary pain.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on psychological therapy for chronic primary pain.

Full details of the evidence and the committee's discussion are in evidence review F: psychological therapy for chronic primary pain.

Acupuncture for chronic primary pain

1.2.5 Consider a single course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system, for people aged 16 years and over to manage chronic primary pain, but only if the course:

  • is delivered in a community setting and

  • is delivered by a band 7 (equivalent or lower) healthcare professional with appropriate training and

  • is made up of no more than 5 hours of healthcare professional time (the number and length of sessions can be adapted within these boundaries) or

  • is delivered by another healthcare professional with appropriate training and/or in another setting for equivalent or lower cost.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on acupuncture for chronic primary pain.

Full details of the evidence and the committee's discussion are in evidence review G: acupuncture for chronic primary pain.

Electrical physical modalities for chronic primary pain

1.2.6 Do not offer any of the following to people aged 16 years and over to manage chronic primary pain because there is no evidence of benefit:

  • TENS

  • ultrasound

  • interferential therapy.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on electrical physical modalities for chronic primary pain.

Full details of the evidence and the committee's discussion are in evidence review H: electrical physical modalities for chronic primary pain.

Pharmacological management of chronic primary pain

1.2.7 Consider an antidepressant, either amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline, for people aged 18 years and over to manage chronic primary pain, after a full discussion of the benefits and harms.

In April 2021, this was an off-label use of these antidepressants. See NICE's information on prescribing medicines.

1.2.8 Seek specialist advice if pharmacological management with antidepressants is being considered for young people aged 16 to 17 years.

1.2.9 If an antidepressant is offered to manage chronic primary pain, explain that this is because these medicines may help with quality of life, pain, sleep and psychological distress, even in the absence of a diagnosis of depression.

1.2.10 Do not initiate any of the following medicines to manage chronic primary pain in people aged 16 years and over:

  • antiepileptic drugs including gabapentinoids, unless gabapentinoids are offered as part of a clinical trial for complex regional pain syndrome (see the recommendation for research on pharmacological interventions)

  • antipsychotic drugs

  • benzodiazepines

  • corticosteroid trigger point injections

  • ketamine

  • local anaesthetics (topical or intravenous), unless as part of a clinical trial for complex regional pain syndrome (see the recommendation for research on pharmacological interventions)

  • local anaesthetic/corticosteroid combination trigger point injections

  • non-steroidal anti-inflammatory drugs

  • opioids

  • paracetamol.

    Pregabalin and gabapentin (gabapentinoids) are Class C controlled substances (under the Misuse of Drugs Act 1971) and scheduled under the Misuse of Drugs Regulations 2001 as Schedule 3. Evaluate patients carefully for a history of drug misuse before prescribing and observe patients for development of signs of misuse and dependence (MHRA Drug Safety Update April 2019).

1.2.11 If a person with chronic primary pain is already taking any of the medicines in recommendation 1.2.10, review the prescribing as part of shared decision making:

  • explain the lack of evidence for these medicines for chronic primary pain and

  • agree a shared plan for continuing safely if they report benefit at a safe dose and few harms or

  • explain the risks of continuing if they report little benefit or significant harm, and encourage and support them to reduce and stop the medicine if possible.

1.2.12 When making shared decisions about whether to stop antidepressants, opioids, gabapentinoids or benzodiazepines, discuss with the person any problems associated with withdrawal.

1.2.13 For recommendations on stopping or reducing antidepressants, see the NICE guideline on depression in adults.

1.2.15 For recommendations on cannabis-based medicinal products, including recommendations for research, see the NICE guideline on cannabis-based medicinal products.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on pharmacological management for chronic primary pain.

Full details of the evidence and the committee's discussion are in evidence review J: pharmacological management for chronic primary pain.

Terms used in this guideline

Chronic pain

Pain that persists or recurs for more than 3 months. This includes both chronic primary pain and chronic secondary pain, which can coexist. Other terms used include persistent pain and long-term pain.

Chronic primary pain

Chronic primary pain has no clear underlying condition or the pain or its impact is out of proportion to any observable injury or disease. The mechanisms underlying chronic primary pain are only partially understood and the definitions are fairly new. All forms of pain can cause distress and disability, but these features are particularly prominent in presentations of chronic primary pain. This guideline is consistent with the ICD-11 definition of chronic primary pain.

Fibromyalgia (chronic widespread pain) is a type of chronic primary pain. ICD-11 also categorises complex regional pain syndrome, chronic primary headache and orofacial pain, chronic primary visceral pain and chronic primary musculoskeletal pain as types of chronic primary pain.

Flare-up

A flare‑up is a sudden, temporary worsening of symptoms. Usually this refers to more intense pain on a day‑to‑day basis. It can also refer to a change in fatigue, stiffness, function or disease activity. Flare‑ups can be unpredictable and the time they last can vary.

Pain management programme

This guideline defines a pain management programme as any intervention that has 2 or more components, including a physical and a psychological component, delivered by trained people, with some interaction/coordination between the 2 components.

  • National Institute for Health and Care Excellence (NICE)