Chronic Pain

Authored by , Reviewed by Prof Cathy Jackson | Last edited | Certified by The Information Standard

This article is for Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find one of our health articles more useful.

Chronic pain tends to be very difficult to manage because of its complex natural history, unclear aetiology and poor response to therapy. Chronic pain is characterised by pain which persists despite adequate time for healing. There is no clear definition but it is often defined as pain that has been present for more than 12 weeks.[1]

Chronic pain is not simply a physical problem. It is often associated with severe and extensive psychological, social and economic factors. Apart from poor general physical health and disability there may also be depression, unemployment, and family stress. Many of these factors interact, and the whole picture needs to be be considered when managing individual patients. The impact of chronic pain on patients' lives varies from minor restrictions to complete loss of independence.

Chronic pain is common within the community, but there are few substantial data. Approximately 18% of the population are currently affected by moderate to severe chronic pain.[1]

A systematic search of multiple databases found a one-month prevalence of moderate-to-severe non-cancer chronic pain in Europe of 19%.[2]One study found that short education, poor self-rated health, high body mass index and physical strain at work were predictors of chronic pain.[3]

It is important to assess severity, impact and type of pain before starting treatment. Brief and well validated tools are available for the assessment of pain in non-specialist settings. These include tools to measure severity of pain and/or its functional impact, tools to identify neuropathic pain, and tools to predict risk of chronicity in acute pain presentations.

The assessment should include a concise history, examination and biopsychosocial assessment, identifying pain type (neuropathic/nociceptive/mixed), severity, functional impact and context.

Biomedical assessment

  • Thorough pain history assessing each discrete pain (site, character, intensity, onset, precipitants, duration, intensity, exacerbating and relieving factors, night pain, perceived cause), systemic symptoms, past medical history.
  • Physical examination (including behavioural response to examination).
  • Previous investigations (and the patient’s understanding).
  • Previous and current treatment (including response, specialised treatments, side-effects, misconceptions, fixed beliefs, messages from other health professionals).

Psychological assessment

  • Consider low mood, anxiety or depression.
  • Psychiatric history, alcohol and illicit drug use, misuse, dependence or addiction, history of physical or sexual abuse
  • Identify yellow flags, loss of confidence, poor motivation, reluctance to modify lifestyle, unrealistic expectations of self and others.

Social assessment

Ability to self care, occupational performance, influence of family on pain behaviour, dissatisfaction at work, secondary gain (family overprotection, benefits, medico-legal compensation).

Yellow flags

Yellow flags are psychosocial indicators suggesting increased risk of progression to long-term distress, disability and pain (red flags are clinical indicators of possible serious underlying conditions).

Biomedical yellow flags: severe pain or increased disability at presentation, previous significant pain episodes, multiple site pain, non-organic signs, iatrogenic factors.

Psychological yellow flags: belief that pain indicates harm, an expectation that passive rather than active treatments are most helpful, fear avoidance behaviour, catastrophic thinking, poor problem solving ability, passive coping strategies, atypical health beliefs, psychosomatic perceptions, high levels of distress.

Social yellow flags: low expectation of return to work, lack of confidence in performing work activities, heavier work, low levels of control over rate of work, poor work relationships, social dysfunction, medico-legal issues.

Causes of diffuse musculoskeletal pain, including:

Although it is essential to make an accurate diagnosis regarding any underlying aetiology for the pain, a great deal of care and skill is often required to avoid unnecessary and inappropriate investigations and referrals, which only serve to increase the underlying anxiety of the patient and their family. A balance must be struck between ensuring that important conditions are excluded whilst avoiding an endless quest for a (sometimes non-existent) physical diagnosis.

Coping styles that include 'seeking social support' and 'confrontation' are important predictors for positive social adjustment; low social self-esteem and high social anxiety are linked with depression and poor outcome.[4]

Passive coping

Passive coping is deemed detrimental to health outcomes and is associated with increased pain, increased disability and depression. Examples of passive coping include:

  • Giving up social activities.
  • Relying on health professionals and medications to relieve pain.

Active coping

Active coping is associated with less pain, disability and depression, and is therefore most recommended. However, increased disability itself may cause less active coping.

See also the separate articles on Pain and Pain Relief and Neuropathic Pain and its Management.

The optimum approach is likely to involve other members of the primary care team, including nurses, pharmacists, physiotherapists, counsellors and occupational therapists. It may also include liaison with social services, employers, and benefits agencies.

Encouraging the patient to have an attitude of positive coping is beneficial. A compassionate, patient-centred approach to assessment and management of chronic pain is likely to improve the chances of successful outcome.[1]

Self-management should be encouraged from an early stage of a pain condition and as part of a long-term management strategy.[1]There are no proven, comprehensive treatments in primary care for patients with medically unexplained symptoms.[5]Management must be tailored for each individual patient.[6]

The treatment should be not just aimed at pain relief but also aimed at changing pain behaviour and improving function. The goals of treatment must be realistic and should be focused on restoration of normal function (minimal disability), better quality of life, reduction of use of medication and prevention of relapse of chronic symptoms.[7]

Referral should be considered when non-specialist management is failing, chronic pain is poorly controlled, there is significant distress, and/or where specific specialised intervention or assessment is considered.[1]

Non-opioid analgesics (simple and topical)[1]

  • Non-steroidal anti-inflammatory drugs (NSAIDs) should be considered in the treatment of patients with chronic nonspecific low back pain.
  • Paracetamol should be considered alone or in combination with NSAIDs in the management of pain in patients with hip or knee osteoarthritis in addition to non-pharmacological treatments.
  • Topical NSAIDs should be considered in the treatment of patients with chronic pain from musculoskeletal conditions, particularly for patients who cannot tolerate oral NSAIDs.
  • Topical capsaicin patches should be considered in the treatment of patients with peripheral neuropathic pain when first-line pharmacological therapies have been ineffective or not tolerated.
  • Topical lidocaine should be considered for the treatment of patients with postherpetic neuralgia if first-line pharmacological therapies have been ineffective.
  • Topical rubefacients should be considered for the treatment of pain in patients with musculoskeletal conditions if other pharmacological therapies have been ineffective.


  • Strong opioids should be considered as an option for pain relief for patients with chronic low back pain or osteoarthritis, but only continued if there is ongoing pain relief.
  • All patients on strong opioids should be assessed regularly for changes in pain relief, side-effects and quality of life, with consideration given to a gradual reduction to the lowest effective dose.
  • It may be necessary to trial more than one opioid sequentially, as both effectiveness and side-effects vary between opioids.
  • Signs of abuse and addiction should be sought at re-assessment of patients using strong opioids.
  • The minimal effective dose should be used to avoid increased problems of fracture and overdose that may occur on higher doses.
  • Specialised referral or advice should be considered if there are concerns about rapid-dose escalation with continued unacceptable pain relief, or if more than 180 mg/day morphine equivalent dose is required.

Anti-epilepsy drugs[1]

  • Gabapentin should be considered for the treatment of patients with neuropathic pain.
  • Pregabalin is recommended for the treatment of patients with neuropathic pain if other first- and second-line pharmacological treatments have failed.
  • Pregabalin is recommended for the treatment of patients with fibromyalgia.
  • Failure to respond after an appropriate dose for several weeks should result in trial of a different medication.
  • Carbamazepine should be considered for the treatment of patients with neuropathic pain.


  • Patients with chronic pain conditions using antidepressants should be reviewed regularly.
  • Tricyclic antidepressants should not be used for the management of pain in patients with chronic low back pain.
  • Amitriptyline (25-125 mg/day) should be considered for the treatment of patients with fibromyalgia and neuropathic pain (excluding HIV-related neuropathic pain).
  • Duloxetine should be considered for the treatment of patients with diabetic neuropathic pain if other first- or second-line pharmacological therapies have failed. Duloxetine should be considered for the treatment of patients with fibromyalgia or osteoarthritis.
  • Fluoxetine should be considered for the treatment of patients with fibromyalgia.
  • Depression is a common comorbidity with chronic pain. Patients should be monitored and treated for depression when necessary.

Psychological interventions[1]

  • Referral to a pain management programme should be considered for patients with chronic pain.
  • Brief education should be given to patients with chronic pain in order to help patients continue to work.
  • Relaxation methods, patient education.[6]
  • Psychotherapy: behavioural and cognitive psychotherapies.[8]
  • Active management of stress: stress has not been proved to be a causal factor, but it seems to act as an exacerbating factor in disease activity and to have an impact on the quality of life.[9]
  • Health professionals should be aware of the possibility that their own behaviour, and the clinical environment, can impact on reinforcement of unhelpful responses.

Behavioural therapies[1]

  • Progressive relaxation or electromyographic (EMG) biofeedback should be considered for the treatment of patients with chronic pain.
  • Clinicians should be aware of the possibility that their own behaviour, and the clinical environment, can reinforce unhelpful responses to treatments.

Cognitive behavioural therapy[1]

  • Cognitive behavioural therapy should be considered for the treatment of patients with chronic pain.
  • Acceptance and commitment therapy has also been shown to be effective.[10]
  • Internet-based educational and therapeutic programmes have been associated with significant decreases in pain severity, pain-related interference and emotional burden, perceived disability, catastrophising, and pain-induced fear.[11]

Physical therapies[1]

  • Exercise and exercise therapies, regardless of their form, are recommended in the management of patients with chronic pain.
  • Advice to stay active should be given in addition to exercise therapy for patients with chronic low back pain to improve disability in the long term. Advice alone is insufficient.
  • Physiotherapy and occupational therapy have an important role in functional restoration for patients. Recreational therapy can help the patient with chronic pain take part in pleasurable activities that help decrease pain.

Manual therapy

  • Manual therapy should be considered for short-term relief of pain for patients with chronic low back pain.
  • Manual therapy, in combination with exercise, should be considered for the treatment of patients with chronic neck pain.


  • Exercise and exercise therapies are recommended in the management of patients with chronic pain.
  • Advice to stay active should be given in addition to exercise therapy for patients with chronic low back pain to improve disability in the long term. Advice alone is insufficient.
  • The following approaches should be used to improve adherence to exercise:
    • Supervised exercise sessions.
    • Individualised exercises in group settings.
    • Addition of supplementary material.
    • Provision of a combined group and home exercise programme.


  • Transcutaneous electrical nerve stimulation (TENS) should be considered for the relief of chronic pain.
  • Low-level laser therapy should be considered as a treatment option for patients with chronic low back pain.

Complementary therapies[1]

  • Acupuncture should be considered for short-term relief of pain in patients with chronic low back pain or osteoarthritis.

Other interventions

  • Nerve blocks and other spinal interventions - eg, epidural injections for chronic back pain.[12]
  • Prolonged physical suffering.
  • Depression.
  • Sleep disturbance.
  • Marital or family problems.
  • Negative effects on work and loss of employment.[13]
  • Disability.
  • Adverse medical reactions from long-term therapy.

Chronic pain has a detrimental effect on physical health, daily activity, psychological health, employment and economic well-being; 45 million working days/year in the UK are lost due to back pain. Chronic pain is associated with:

  • Reduced ability to work; more strain is perceived with regard to future uncertainty, balancing multiple roles and difficulties accepting the disease than the workplace itself. For example, patients who have inflammatory arthritis, more frequent severe pain, greater workplace activity limitations, fewer hours of work and less co-worker support reported most strain.[14]
  • Marital and family problems.
  • Difficulty in performing everyday tasks.
  • Physical disability.
  • Depression.
  • Adolescents who suffer from chronic pain are at increased risk of suicidal thoughts and attempted suicide.[15]
  • Sleep disturbance.
  • Helplessness.
  • Problems with medications: side-effects, interactions, dependence.
  • The prognosis is variable but often poor.
  • However, considerable improvement is possible with suitable support and management.

Further reading and references

  1. ; Scottish Intercollegiate Guidelines Network - SIGN (Dec 2013)

  2. ; Epidemiology of chronic non-cancer pain in Europe: narrative review of Curr Med Res Opin. 2011 Feb27(2):449-62. Epub 2011 Jan 3.

  3. ; A population-based cohort study on chronic pain: the role of opioids. Clin J Pain. 2010 Nov-Dec26(9):763-9.

  4. ; Coping strategies as predictors of psychosocial adaptation in a sample of elderly veterans with acquired lower limb amputations. Soc Sci Med. 2006 Jan62(1):208-16. Epub 2005 Jun 28.

  5. ; Treating patients with medically unexplained symptoms in primary care. J Gen Intern Med. 2003 Jun18(6):478-89.

  6. ; Relaxation and imagery for chronic, nonmalignant pain: effects on pain symptoms, Pain Manag Nurs. 2010 Sep11(3):159-68. Epub 2009 Sep 8.

  7. ; Make a CHANGE: optimising communication and pain management decisions. Curr Med Res Opin. 2011 Feb27(2):481-8. Epub 2011 Jan 3.

  8. ; Antidepressants and cognitive-behavioral therapy for symptom syndromes. CNS Spectr. 2006 Mar11(3):212-22.

  9. ; Stress and coping strategies in systemic lupus erythematosus: a review. Neuroimmunomodulation. 200613(5-6):283-93. Epub 2007 Aug 6.

  10. ; A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain. 2011 Sep152(9):2098-107. doi: 10.1016/j.pain.2011.05.016. Epub 2011 Jun 17.

  11. ; A randomized controlled evaluation of an online chronic pain self management program. Pain. 2012 Feb153(2):319-30. doi: 10.1016/j.pain.2011.10.025. Epub 2011 Nov 30.

  12. ; Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines. Pain Physician. 2005 Jan8(1):1-47.

  13. ; The impact and burden of chronic pain in the workplace: a qualitative systematic review. Pain Pract. 2012 Sep12(7):578-89. doi: 10.1111/j.1533-2500.2012.00547.x. Epub 2012 Mar 29.

  14. ; Arthritis symptoms, the work environment, and the future: measuring perceived job strain among employed persons with arthritis. Arthritis Rheum. 2007 Jun 1557(5):738-47.

  15. ; Chronic pain in adolescents is associated with suicidal thoughts and behaviors. J Pain. 2011 Oct12(10):1032-9. doi: 10.1016/j.jpain.2011.03.004.

I sometimes have pain on my left side by my rib it's sharp but it's quick and sometimes the pain at the bottom of sternum to I do have acid reflux could this be that I had a scope couple years ago...

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