Pain Management for GPs: Your Survival Guide
Because "take two paracetamol and call me in the morning" isn't always the answer (but sometimes it actually is)
🍵 Tea-Friendly Learning ⏰ For GP Trainees Short on Time 🚩 Red Flag Focused
Date Updated: March 3, 2026
⭐ Executive Summary: What You'll Master Today
Because you have 47 other things to do before lunch, and that's just the morning list
✅ What You'll Learn
- • WHO Analgesic Ladder (updated 2026)
- • NICE NG193 chronic pain guidelines
- • Red flags that'll wake you up at 3am
- • When to stop escalating opioids
- • NSAID safety (beyond "bad for kidneys")
- • Depression-pain connection
- • SCA consultation scripts
📈 Quick Facts at a Glance
30-40%
of UK adults have chronic pain
10-20%
of chronic pain has a clear structural cause
50-60%
of chronic pain sufferers have anxiety or depression
5x
more frequent consultations with patients who have chronic pain
30-40%
improvement in chronic pain with exercise
~15%
of patients prescribed co-codamol develop dependence
🧭 Quick Navigation
📥 Downloads
path: PAIN MANAGEMENT
- .listing
- amitriptyline.ppt
- fentanyl patches.pdf
- neuropathic pain - diagnosing and managing.doc
- neuropathic pain - pregablin or gabapentin.pdf
- opiate detox - an intro.pdf
- opiate detox - flowchart.pdf
- opiod guidelines.doc
- opioid conversion chart - leeds 2016.pdf
- opioid conversion charts.pdf
- opioids - hdr session.pptx
- opioids.pdf
- pain part 1.ppt
- pain part 2.ppt
- pain part 3.ppt
- patient leaflets on pain drugs.doc
🔗 Web Resources
🔗 NICE NG193 Chronic Pain Guidelines 🔗 NICE CKS Chronic Pain 🔗 SIGN Chronic Pain Guidelines 🔗 RCGP Pain Management Resources 🔗 Moving Medicine - fabulous resource - go look at it 🔗 Flippin' Pain - For Pain Management 🔗 Living Well With Pain (excellent) - send patients to this website 🔗 Escape Pain - rehab for chronic joint pain - send patients to this website
🧠
Brainy Bites: Essential Pain Management Wisdom
⭐ Golden Rules
- ✅ Pain reduction, not elimination, is the goal
- ✅ Always screen for depression in chronic pain
- ✅ Escalating analgesia without functional gain = rethink
- ✅ Short-term opioids only, with clear stop dates
- ✅ NSAIDs: check heart, kidneys, stomach, age
- ✅ OA Pain Key: Exercise is THE most effective treatment - GPs must emphasize this more and show patients specific exercises. Exercise can eliminate the need for ANY medication.
Remember: You don't need to be a pain specialist to provide excellent pain care. You just need to know when to worry, when to treat, and when to refer.
☕ Now go reward yourself with that well-deserved coffee
🎯 Memory Aids
SOCRATES (Pain History)
Site, Onset, Character, Radiation, Associated symptoms, Time course, Exacerbating/Relieving, Severity
NSAID Safety: "HAGS"
Heart disease, Age >65, GI risk, Stomach ulcers
Triple Whammy
ACE inhibitor + Diuretic + NSAID = Acute kidney injury risk
Dependence-Prone: "CTD"
Co-codamol, Tramadol, Dihydrocodeine (DF118)
Key Clinical Pearls
- • Co-codamol dependency: more common than you think (~15% develop dependence)
- • Diclofenac: avoid in heart disease
- • Capsaicin: takes weeks to work, burns initially
- • Tramadol: seizure risk + serotonin syndrome
- • Pain vs imaging: intensity often correlates poorly with findings
✅ Paradigm-Shifting Summary for GPs
Chronic pain is less about damaged tissues and more about a sensitised nervous system interacting with mood, behaviour, sleep, and activity.
Which means the most effective treatments are often: exercise, sleep improvement, psychological therapies, self-management —not scans, injections, or opioids.
⚠️ 🚨 Red Flags & Critical Conditions
🚨 Emergency (999/A&E)
- • Cauda equina syndrome (saddle anaesthesia, bowel/bladder dysfunction)
- • Spinal cord compression (progressive neurological deficit)
- • Compartment syndrome (severe pain, swelling, paraesthesia)
- • Septic arthritis (hot, swollen joint + fever)
- • Acute abdomen with peritonism
- • Sudden severe headache (thunderclap)
⏰ Urgent (Same Day) Referral
- • Suspected fracture with neurovascular compromise
- • Renal colic with fever/AKI
- • Cancer pain escalation
- • Opioid overdose signs (sedation, respiratory depression)
- • Severe withdrawal symptoms
- • New neurological signs in chronic pain
ℹ️
Patient Safety Net:
"If your pain suddenly gets much worse, you develop numbness around your bottom or private parts, or you have trouble controlling your bladder or bowels, you need to go to A&E immediately. Don't wait - call 999 if you can't get there quickly."
"If your pain suddenly gets much worse, you develop numbness around your bottom or private parts, or you have trouble controlling your bladder or bowels, you need to go to A&E immediately. Don't wait - call 999 if you can't get there quickly."
📈 📊 WHO Analgesic Ladder (Updated 2026)
Your step-by-step guide to not accidentally creating the next opioid crisis
STEP 1: MILD PAIN
Non-Opioid Analgesics
- • Paracetamol 1g QDS (first-line)
- • Ibuprofen 400mg TDS (if safe)
- • Naproxen 250-500mg BD
- • Topical NSAIDs for localized pain
- • ± Adjuvants: Amitriptyline, gabapentin
STEP 2: MODERATE PAIN
Weak Opioids + Non-Opioids
- • Co-codamol 30/500 (max 8 tablets/day)
- • Tramadol 50-100mg QDS
- • Dihydrocodeine 30mg QDS
- • Continue Step 1 medications
- • Review in 1-2 weeks
STEP 3: SEVERE PAIN
Strong Opioids + Non-Opioids
- • Morphine (immediate/modified release)
- • Oxycodone (specialist initiation)
- • Fentanyl patches (stable patients only)
- • Continue non-opioids
- • Specialist referral often needed
ℹ️
Key Principles:
By the mouth: Oral route preferred | By the clock: Regular dosing, not PRN | By the ladder: Stepwise escalation | For the individual: Personalized approach | Attention to detail: Monitor and adjust
By the mouth: Oral route preferred | By the clock: Regular dosing, not PRN | By the ladder: Stepwise escalation | For the individual: Personalized approach | Attention to detail: Monitor and adjust
💊 💊 NSAIDs: What UK GPs Must Know
More than just "bad for kidneys" - your complete NSAID safety guide
| Drug | Upper GI Risk (NO PPI) | Upper GI Risk (WITH PPI) | MI/CV Risk | Clinical Notes |
|---|---|---|---|---|
| Ibuprofen | Low–moderate (mild) | Low (mild) | Low–moderate (mild) | Among lowest GI risk of traditional NSAIDs; CV risk increased vs non‑use but generally lower than diclofenac at usual doses. |
| Naproxen | Moderate (mod) | Low–moderate (mild) | Low–moderate (mild) (possibly most favourable) | Higher GI risk than ibuprofen; historically considered to have a relatively favourable CV profile, but still increases MI risk vs non‑use. |
| Diclofenac | Moderate–high (high) | Moderate (mod) | High (high) | One of the worst CV profiles; avoid in established IHD / high CV risk; GI risk similar to or higher than naproxen at comparable doses. |
| Celecoxib | Low–moderate (mild) | Low (mild) | Low–moderate (mild) | COX‑2 selective, substantially lower upper‑GI complication rates than non‑selective NSAIDs; in PRECISION, non‑inferior to ibuprofen and naproxen for major CV events. |
| Etoricoxib | Low–moderate (mild) | Low (mild) | High (high) | COX‑2 selective, good upper‑GI profile, but multiple analyses and regulatory reviews flag relatively high CV risk, at least comparable to or greater than diclofenac. |
ℹ️ 📊 Approximate Absolute Risk Numbers (Teaching Purposes Only)
For average-risk 40–70-year-olds (class ballparks, not drug-specific):
GI Bleeding Risk:
- • Non-selective NSAID: ~2–4 per 1000 person-years (≈0.2–0.4%/yr)
- • Very elderly: ~20 per 1000 person-years
- • COX-2 vs non-selective: ~50–60% relative reduction
- • PPI co-therapy: ~30–50% relative reduction (upper GI only)
CV Risk:
- • Any NSAID: ≈20–50% relative increase in acute MI risk vs non‑use
- • Diclofenac & high-dose regimens: at the higher end
- • Naproxen: generally most favourable CV profile
Note: Per-drug "0.2% vs 0.3% per year" figures are more precision than the data genuinely support.
Key Clinical Decision Messages
High GI risk, low CV risk:
→ Consider celecoxib/etoricoxib + PPI.
High CV risk, moderate GI risk:
→ Prefer naproxen + PPI, lowest CV risk.
Diclofenac:
→ Avoid long-term where possible because of CV risk, especially in IHD, stroke, PAD, HF.
Key Takeaways (Exam-Friendly)
GI Risk (highest → lowest):
Naproxen ≈ Diclofenac > Ibuprofen > Celecoxib ≈ Etoricoxib
• PPI reduces GI bleeds by ~50–70% for all NSAIDs
• COX-2 inhibitors + PPI = lowest absolute risk combination
CV Risk (highest → lowest):
Diclofenac > Etoricoxib > Celecoxib ≈ Ibuprofen > Naproxen
• If high CV risk: → Naproxen (with PPI if GI risks)
• If high GI risk: → Celecoxib or Etoricoxib, ideally with PPI
GI Risk Factors
- • Age >65 years
- • Previous peptic ulcer
- • Concurrent steroids
- • Anticoagulants/antiplatelets
- • H. pylori infection
Consider PPI co-prescription
CV Risk Factors
- • Ischaemic heart disease
- • Cerebrovascular disease
- • Heart failure
- • Peripheral arterial disease
- • Uncontrolled hypertension
Naproxen preferred if NSAID needed
Renal Protection
- • Check eGFR before prescribing
- • Avoid in CKD stage 4-5
- • Beware "triple whammy"
- • Monitor in elderly
- • Stop if dehydrated
ACEi + Diuretic + NSAID = AKI risk
🛡️ PPI Gastroprotection Guidelines (NICE)
Mandatory PPI Co-prescription:
- • Age ≥65 years (most guidelines)
- • Previous peptic ulcer disease
- • History of GI bleeding/perforation
- • Concurrent anticoagulants/antiplatelets
- • Concurrent corticosteroids
- • High-dose NSAID therapy
- • Multiple risk factors present
PPI Choice & Dosing:
- • Omeprazole 20mg daily (first-line)
- • Lansoprazole 30mg daily (alternative)
- • Continue for duration of NSAID therapy
- • Review need regularly
- • Consider H. pylori testing if recurrent symptoms
ℹ️
NICE Guidance: All patients on long-term NSAIDs for RA/OA should be offered PPI gastroprotection
🧠 🧠 Chronic Pain & Mental Health
The biopsychosocial approach: because pain isn't just about nociceptors
Depression-Pain Connection
- • 30-60% of chronic pain patients have depression
- • Shared neurochemical pathways (serotonin, noradrenaline)
- • Central sensitization amplifies pain signals
- • Sleep disturbance worsens pain perception
- • Reduced coping capacity
💡
Key Message: Treating depression often reduces pain intensity more effectively than increasing analgesia
Red Flags for Hidden Depression
- • Poor sleep quality
- • Low motivation/anhedonia
- • Reduced activity levels
- • Catastrophizing language
- • "Nothing helps" pattern
- • Frequent GP attendances
- • Escalating opioid requests
NICE NG193 Key Recommendations (2026)
First-Line Interventions
- • Supervised group exercise programmes
- • Psychological therapies (CBT, ACT)
- • Acupuncture (consider)
- • Self-management support
Avoid/Caution
- • Long-term opioids (avoid initiation)
- • Paracetamol alone (limited evidence)
- • NSAIDs long-term
- • Antiepileptics (gabapentin/pregabalin)
SCA Consultation Script: Chronic Pain
Validation:
"I can see this pain is really affecting your life. Chronic pain is real and we take it seriously."
Explanation:
"Pain and mood often influence each other. When mood dips, pain signals can feel louder in the brain."
Reattribution:
"This doesn't mean the pain is 'in your head' - it means we can work on multiple approaches to help you feel better."
Goal Setting:
"Let's focus on what you'd like to be able to do again, rather than just the pain score."
Safety Net:
"If your pain suddenly changes or gets much worse, please come back to see us."
📊 🎯 Specific Pain Conditions
Acute Renal Colic
First-Line Management
- • NSAID (if safe) - diclofenac 75mg IM or 50mg PO TDS
- • Paracetamol 1g QDS
- • Anti-emetic if vomiting
- • Encourage fluid intake
Urgent Referral If:
- • Fever (suggests infection)
- • AKI or rising creatinine
- • Solitary kidney
- • Uncontrolled pain despite adequate analgesia
- • Persistent vomiting
Osteoarthritis Pain
Stepwise Approach
- • Exercise + weight loss (most important)
- • Topical NSAIDs first-line for hands/knees
- • Paracetamol regular dosing
- • Oral NSAIDs if needed (lowest risk agent)
- • Capsaicin cream for hand/knee OA
Capsaicin - How to Use
- • Apply thin layer 3-4 times daily
- • Requires consistent use for 2-4 weeks
- • Initial burning sensation is common
- • Wash hands carefully after application
- • Avoid contact with eyes/mucous membranes
Bone Pain in Cancer
Key Principles
- • NSAIDs very effective for inflammatory bone pain
- • Radiotherapy often highly effective
- • Bisphosphonates for multiple bone metastases
- • Early palliative care involvement
- • Regular breakthrough analgesia
When to Refer
- • Escalating pain despite WHO ladder
- • Incident pain (movement-related)
- • Neuropathic component
- • Psychological distress
- • Complex medication regimen needed
Neuropathic Pain
First-Line Options
- • Amitriptyline 10-75mg nocte
- • Duloxetine 60mg daily
- • Gabapentin 300mg TDS (titrate up)
- • Pregabalin 75mg BD (titrate up)
Clinical Clues
- • Burning, shooting, electric shock-like
- • Allodynia (light touch painful)
- • Hyperalgesia (increased pain response)
- • Often worse at night
- • Associated numbness/tingling
🛡️ ⚠️ Opioid Stewardship
Being careful with opioids: because "just a bit more" can become "a lot more"
⚠️ Key Risks
- • Tolerance: Need increasing doses for same effect
- • Hyperalgesia: Paradoxical increase in pain sensitivity
- • Dependence: Physical withdrawal symptoms
- • Addiction: Psychological craving and loss of control
- • Respiratory depression: Especially with alcohol/benzos
- • Constipation: Universal side effect
📋 Prescribing Principles
- • Clear indication: Severe pain, short-term use
- • Lowest effective dose
- • Shortest duration (usually <7 days acute pain)
- • Regular review - don't just repeat
- • Set expectations - discuss duration upfront
- • Monitor function not just pain scores
When to Stop Escalating Opioids
- • No functional improvement despite dose increases
- • Side effects outweigh benefits
- • Signs of misuse: Early requests, lost prescriptions, doctor shopping
- • Morphine equivalent >120mg/day (specialist territory)
- • Patient requesting specific drugs/routes
- • Concurrent substance abuse
Tapering Strategy
General Principles
- • Slow reduction: 10-25% every 1-4 weeks
- • Patient agreement essential
- • Expect some discomfort - distinguish from withdrawal
- • Support services: Psychology, physiotherapy
Withdrawal Symptoms
- • Physical: Flu-like symptoms, GI upset, insomnia
- • Psychological: Anxiety, irritability, depression
- • Peak: 1-3 days, resolve within 1-2 weeks
- • Support: Loperamide, paracetamol, reassurance
👥 🏥 Professional & Ethical Considerations
Ethical Dilemmas in Pain Management
Autonomy vs Beneficence
Patient requests opioids but you believe they're harmful. Balance patient choice with professional duty.
Justice vs Individual Care
Limited resources (physiotherapy, pain clinic referrals) vs individual patient needs.
Non-maleficence
"First, do no harm" - but what constitutes harm in chronic pain? Undertreating vs overtreating.
Safeguarding Concerns in Pain Management
Adults at Risk
- • Elderly patients with chronic pain
- • Learning disabilities + pain communication
- • Mental health conditions
- • Substance abuse history
- • Social isolation due to pain
Red Flags
- • Unexplained injuries in vulnerable adults
- • Carer controlling medication access
- • Financial abuse (selling medications)
- • Neglect of pain management needs
- • Coercion in treatment decisions
Mental Capacity in Pain Management
Capacity Assessment
- • Understand the information
- • Retain the information
- • Weigh up the pros and cons
- • Communicate their decision
Factors Affecting Capacity
- • Severe pain affecting concentration
- • Opioid-induced cognitive impairment
- • Depression/anxiety
- • Delirium in elderly patients
- • Learning disabilities
Health Inequalities in Pain Management
Disparities in Pain Care
- • Gender: Women's pain often minimized
- • Ethnicity: Racial bias in pain assessment
- • Age: Elderly pain undertreated
- • Socioeconomic: Access to private treatments
- • Geography: Rural vs urban service access
Promoting Equity
- • Recognize your own biases
- • Use validated pain assessment tools
- • Consider cultural factors in pain expression
- • Ensure interpreter services when needed
- • Advocate for equal access to services