Chronic pain: Quality prescribing - A guide for improvement 2026-2029
1. Aims: What matters to the individual about their condition(s)?
Review diagnoses and consider:
- Therapeutic objectives of drug therapy
- Management of existing health problems
- Prevention of future health issues, including lifestyle advice
Ask person to complete PROMs (Questions to answer before medicines review) before their review
Person specific issues to address
- Ensure person-centred approach
- Consider non-pharmacological options
- Discuss achievable goals and realistic timescales
2. Need: Identify essential drug therapy
Identify essential drugs (not to be stopped without specialist advice)
- Drugs that have essential replacement functions (e.g. levothyroxine)
- Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)
Person specific issues to address
- Although not classed as an essential medicine, prescribers should be aware of the potential for dependence and withdrawal reaction with some of these medicines
- Before initiation of antidepressants, opioids and gabapentinoids discuss the risk of dependency/ withdrawal reaction with use
3. Does the individual take unnecessary drug therapy?
Identify and review the continued need for drugs
- what is medication for?
- with temporary indications
- with higher than usual maintenance doses
- with limited benefit/evidence for use
- with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)
Person specific issues to address
- Consider non-pharmacological approaches either alone or as an adjunct to medicines (e.g. CBT)
- All people receiving opioid doses of >50mg MED/day should be reviewed regularly (at least annually) to detect emerging harms and consider ongoing effectiveness
- Identify and review medicines of low/limited clinical value e.g. lidocaine plasters, nefopam
4. Effectiveness: Are therapeutic objectives being achieved?
Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives
- to achieve symptom control
- to achieve biochemical/clinical targets
- to prevent disease progression/exacerbation
- is there a more appropriate medication to achieve goals?
Person specific issues to address
- Total eradication of pain is unlikely, and evidence reviews frequently consider an intervention effective if it reduces pain by 30% to 50%
- Consider non-pharmacological approaches
- Taper and stop opioids in patients who are not benefiting from their use
5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?
Identify individual safety risks by checking for
- appropriate individual targets e.g. HbA1c, BP
- drug-disease interactions
- drug-drug interactions (see ADR table)
- monitoring mechanisms for high-risk drugs
- risk of accidental overdosing
Identify adverse drug effects by checking for
- specific symptoms/laboratory markers (e.g. hypokalaemia)
- cumulative adverse drug effects (see ADR table)
- drugs used to treat side effects caused by other drugs
- Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness
Person specific issues to address
- Consider combinations of high-risk medications e.g. opioids, gabapentinoids, benzodiazepines, antidepressants and antipsychotics
- All people receiving opioid doses of >50mg MED/day should be reviewed regularly (at least annually) to detect emerging harms and consider ongoing effectiveness
- In high-risk individuals e.g. co-morbidities such as sleep apnoea there may be a need for prescribing of naloxone
- Consider impact of renal and hepatic function on dosing e.g. gabapentinoids, opioids
- Consider cardiovascular risks from NSAIDs and Cox-2 inhibitors
- Reduce paracetamol dose for those with low bodyweight (<50kg) and risk factors for hepatotoxicity
- Consider anticholinergic burden e.g. antidepressants and nefopam
- Consider increased risk of adverse drug effect and drug interactions in frail individuals
6. Sustainability: Is drug therapy cost-effective and environmentally sustainable?
Identify unnecessarily costly drug therapy by
- considering more cost-effective alternatives, formulary choices, safety, convenience
Consider the environmental impact of
- Inhaler use
- Single use plastics
- Medicines waste
- over-ordering
- disposal
- Water pollution
Person specific issues to address
- Identify and review medicines of low/limited clinical value e.g. lidocaine plasters, nefopam
7. Person-centredness: Is the person willing and able to take drug therapy as intended?
Does the person understand the outcomes of the review?
- Consider Teach back
Ensure drug therapy changes are tailored to individual’s preferences. Consider
- is the medication in a form they can take?
- is the dosing schedule convenient?
- what assistance is needed?
- are they able to take medicines as intended?
Agree and communicate plan
- discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
- include lifestyle and holistic management goals
- inform relevant health and social care providers of changes in treatments across the transitions of care
Ask person to complete PROMs (Questions to answer after medicines review) after their review
Agreed plan
- Consider review period for management of chronic pain
- If there is dosage reduction, agree a reduction plan and agree with individual to prevent withdrawal
- Signpost appropriate non-pharmacological support and resources (e.g. Live Well With Pain)