Chronic Pain - Tips for Primary Care.

We are all well aware of how common chronic pain is, and the impact it has. Even by conservative estimates about 20% of the adult population report chronic pain. This topic really came into focus for us four years ago with the new NICE guideline on chronic pain (NG193), which was probably most notable for recommendations on drugs we shouldn’t prescribe (no paracetamol, opiates, benzos, gabapentinoids…).

The NICE guideline felt like a bit of a ‘line in the sand’ confirming that what we had been trying for many years with chronic pain simply wasn’t working - the belief that the principles of managing acute pain with analgesics and needles could be translated to chronic pain, propagated in clinics run by experts in acute pain management, has ultimately been proven to be wrong. 

But the NICE guideline has left us and our patients in a difficult position given the limited service provision for recommended therapies and pain clinics that are overwhelmed. 

So an excellent recent Lancet paper ‘Opportunities for chronic pain self-management’ (Lancet, 2025 Volume 405, Issue 10491, 1781 - 1790) really caught my eye. It was a fascinating insight into the current thinking on the neurobiology of chronic pain, and importantly what psychological principles we can use in primary care.

First a quick reminder on what pain actually is - The International Association for the Study of Pain (IASP) defines pain as ‘an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’ and importantly that ‘pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors’.

Chronic pain is pain that persists or recurs for over 3 months and can be further split into chronic primary pain (cannot be accounted for by another diagnosis e.g. fibromyalgia) and  chronic secondary pain (can be accounted for by another diagnosis e.g. arthritis). However, this simplistic ‘split’ between chronic primary and secondary pain can be unhelpful, as for many people with chronic pain there may be overlap between the two, and as the Lancet review highlights, ‘The experience of pain is dynamic and its categorisation might change over time’. 

Whilst a review of the neurobiology of chronic pain is beyond the scope of this blog (and my brain capacity TBH) in summary there is increasing evidence that multiple neural pathways are remodelled in chronic pain, and importantly that brain imaging is starting to show that psychological interventions can alter these maladaptive neural pathways.

The Lancet paper gives some very useful psychological principles we can build into primary care consultations to help patients self-manage their pain:

1. Acknowledging that the pain is real, and showing empathy and understanding is crucial. 
2. Discussing the neurobiological changes that occur in chronic pain due to neural re-wiring can be helpful to explain how pain develops without observable pathology, as is the IASP pain definition highlighting that pain is in part an emotional experience that can be altered by psychological or social factors. Tame The Beast does a great short video to help explain some of these principles.
3. Assess core beliefs about pain, what the patient understands pain is and challenge core beliefs that suffering is an inevitable consequence of chronic pain.
4. Move the focus away from pain towards function, recognising that repeated failed attempts to control pain have led to further disability. 
5. Give hopeful and confident messages of change through self-management; focusing on valued activities and goals can improve function with pain, and be aware of unhelpful automatic thoughts of future catastrophes.
6. Support using patient-focused resources (see below);  recognise that successful self-management of chronic pain requires a cultural shift from the usual language of pain as a signal of damage not to be ignored.
7. Address and acknowledge time frame and setbacks. Pain management skills take practice and time. Discuss that setbacks are an expected part of the process and that there is unlikely to be a simple uninterrupted slope of improvement, and occasional increases in pain are not a cause for alarm.

The Lancet paper acknowledges that these consultations are challenging and that we can’t tackle the problems of chronic pain on our own - there needs to be sustained changes across multiple systems (not just health). But they conclude that these principles ‘can be more powerful when delivered early and by a trusted, credible, and authoritative health-care provider’ - that, in a nut shell, is us.

Resources for Chronic Pain

• The Sheffield Persistent Pain site has a superb set of resources and information to help patients to live better lives with chronic pain - Sheffield Persistent Pain.
• Live Well With Pain have great resources for clinicians and patients.
• See also Tame the Beast - an excellent set of resources for patients and clinicians which helps re-frame the discussion around persistent pain and how we all need to think about it differently.
• Flippin’ Pain is a public health campaign with a clear goal: To change the way we think about, talk about, and treat persistent pain.