At-a-glance
- First step: classify and assess chronic pain comprehensively (biological + psychological + social impact).
- Chronic primary pain: pain as a condition itself (not fully explained by another diagnosis) — management prioritises supported self-management and psychological interventions.
- Non-pharmacological options: activity-based approaches and psychological therapy (e.g. ACT/CBT-style) are core.
- Medication rules matter: NICE NG193 is explicit about medicines you should not initiate for chronic primary pain.
Assessment (what “good” looks like in 10 minutes)
- Impact: sleep, mood, work, relationships, activity limitation, flare pattern.
- Comorbidities: depression/anxiety, trauma history, sleep apnoea, substance use, medication dependence risks.
- Patient goals: focus on function and quality of life (walking, returning to work, social engagement) rather than a single pain score.
- Red flags: new neurological deficit, systemic symptoms, unexplained weight loss, inflammatory back pain features — investigate/refer appropriately.
Chronic primary pain (NICE NG193 — condensed)
- Offer: supported self-management and psychological therapies (e.g. ACT/CBT-informed approaches) where available; consider a limited course of acupuncture/dry needling within cost/time limits per NICE.
- Do not offer: biofeedback, TENS/ultrasound/interferential therapy for chronic primary pain.
- Consider antidepressants (adults): NICE NG193 allows consideration of an antidepressant for chronic primary pain after a full discussion (used for QoL/sleep/pain modulation, not solely “depression”).
- Do not initiate for chronic primary pain: antiepileptics (including gabapentinoids), antipsychotics, benzodiazepines, ketamine, or corticosteroid trigger point injections.
Frequently asked questions
What’s the key difference between chronic primary and secondary pain?
Chronic primary pain is not fully explained by another condition and is treated as a condition itself; chronic secondary pain is attributable to an underlying diagnosis (e.g., osteoarthritis, neuropathy) where disease-specific management is central.
Are opioids recommended for chronic primary pain?
NICE NG193 emphasises non-pharmacological approaches and is restrictive about pharmacological escalation; avoid initiating dependence-forming medicines for chronic primary pain in most cases and follow local governance.
Why would an antidepressant be used if the patient is not depressed?
NICE NG193 notes antidepressants may help quality of life, pain, sleep and psychological distress even without a diagnosis of depression, after a balanced discussion of benefits and harms.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.