Analgesia in Primary Care
Red Flags — the harms of analgesia and the missed cause
| Red flag | Why it matters | Action |
|---|---|---|
| Opioid + gabapentinoid + alcohol/benzodiazepine | Additive respiratory depression and overdose. | Address combination; take-home naloxone; deprescribe; reduce alcohol |
| Escalating opioids with worsening function (hyperalgesia) | Harm without benefit; dependence; falls; hormonal/immune effects. | Don't escalate; review & deprescribe; non-drug therapies |
| New/changed pain with red flags (cauda equina, fracture, malignancy, infection) | Serious cause masked as "chronic pain". | Investigate/refer urgently; don't just analgese |
| Low mood / self-harm / overdose ideation | Common in chronic pain; raises overdose risk. | Assess/treat mood; safety plan; mental-health support |
| Dependence / running out early / aberrant use | Opioid/gabapentinoid dependence. | Non-judgmental; structured deprescribing; specialist support if needed |
| NSAID harms (GI/renal/CV), paracetamol in liver disease | Analgesics themselves cause harm. | Lowest dose/shortest course; gastroprotection; check renal/hepatic |
✅ Validate first
The pain is real; the patient is not to blame.
"Your pain is real and I believe you — and none of this is your fault. The medication you were given seemed sensible at the time, but the evidence has moved on and it's not serving you well."📉 Why not more opioids
Explain hyperalgesia/harm honestly.
"Strong painkillers actually do very little for long-term pain, and over time they can make the nervous system more sensitive — so more medication can mean more pain and less life, which is what's happened."🏃 The better path
Offer credible, evidence-based alternatives.
"The things that genuinely help long-term pain are movement built up gradually, support to manage the impact, and treating your sleep and mood — and I can get you those, which you've never been offered."🤝 No abandonment
Reassure you'll support the change.
"I'm not going to stop anything suddenly or leave you to struggle. We'll reduce slowly, together, while we build up the things that work — and I'll be here throughout."Work, money and identity
Neil has stopped working. Worklessness in chronic pain is both a consequence and a cause: loss of structure, income, purpose and social contact all amplify pain and low mood, and the longer someone is off, the harder the return. Benefits assessments and money worries add a constant background stress, and some patients fear that improving will threaten their income or be seen as proof they were "putting it on".
Ask what his job was, what he misses, and whether a phased or adjusted return is imaginable. NICE NG59 recommends promoting and facilitating return to work or normal activities for people with low back pain.
"What did you do for work, and what do you miss most about it? I'd like part of our plan to be about getting some of that back — not straight away, but step by step."Family, relationships and carers
Partners and families often become carers, take over tasks and — out of kindness — encourage rest. Irritability from pain, withdrawal effects between doses, sedation and alcohol strain relationships. Family members are also the people who will find him if he overdoses, so they need to know about naloxone and the signs of too much medication.
Ask who is at home, how they are coping, and whether anyone else in the household takes medicines that could be shared or taken by mistake (including children and visitors).
"Who's at home with you, and how are they finding things? Would it help if someone came with you next time, so they hear the plan too — and know what to do if you ever became very drowsy?"Alcohol, sleep and coping
Neil drinks more than he used to. Alcohol is often self-medication for pain, sleep and low mood, and with opioids and a gabapentinoid it multiplies the risk of respiratory depression (MHRA). It also worsens sleep architecture, mood and liver safety for paracetamol. Ask non-judgementally and quantify (AUDIT-C), and ask what else he uses to cope — including over-the-counter codeine, someone else's tablets, or cannabis.
"Lots of people in pain find a drink takes the edge off or helps them sleep — I'm not judging. Can you tell me roughly how much you're having in a typical week? It matters because of how it mixes with your tablets."Mood, hopelessness and safety
Low mood is common in chronic pain and runs both ways: pain worsens mood and low mood amplifies pain. Hopelessness, access to a large supply of opioids and gabapentinoids, and alcohol together make a direct question about self-harm and suicidal thoughts essential — asking does not increase risk. Screen formally (PHQ-9, GAD-7) and ask directly.
"When pain goes on this long, people sometimes feel it's never going to get better, or even that they'd rather not be here. Have you had thoughts like that? I ask everyone in your situation, because it matters for how we keep you safe."Beliefs about pain and medication
Neil's model is "more pain means more damage, so I need stronger painkillers". Fear that movement causes harm (fear-avoidance) and catastrophising predict disability more strongly than scan findings. He may also fear that reducing medication will unleash unbearable pain, not knowing that withdrawal symptoms and opioid-induced hyperalgesia can make pain feel worse on high doses and that many people feel better as doses fall (site opioid protocol, Opioids Aware principles).
"What do you think is going on in your back? And what do you think would happen if we slowly lowered the tablets? I ask because what people believe about their pain makes a real difference to what helps."Past experiences with services
Neil feels no one takes his pain seriously. Previous consultations may have left him feeling dismissed, or accused of drug-seeking. Each dose increase was likely offered in good faith but without a plan to review. Acknowledging the system's part — rather than blaming him — is often what unlocks engagement. Check who prescribes (one prescriber, one pharmacy), and whether he has had pain clinic, physiotherapy or psychology input before.
"It sounds like you've had to fight to be believed, and that the answer each time was a stronger tablet. That's not your fault. I'd like to do things differently with you, and I'll be straight with you all the way through."- Escalating opioids without naming the pain type / assessing function
- Missing the high-risk combination (opioid+gabapentinoid+alcohol)/mood/self-harm
- Not re-screening red flags
- Declining the request without validation or an alternative (patient feels dismissed)
Investigate / safety
Don't just analgese- Red-flag painCauda equina/fracture/malignancy/infection → investigate/refer
- Overdose risk / dangerous comboOpioid+gabapentinoid+alcohol → safety, naloxone
- Self-harm / severe moodMental-health support
NG193 path
Right tools- Chronic primary painExercise/CBT/antidepressant; NOT opioids/gabapentinoids
- On long-term opioids w/o benefitSupported deprescribing
- NeuropathicAmitriptyline/duloxetine/gabapentinoid
WHO ladder
Time-limited- Acute nociceptiveParacetamol ± NSAID; short opioid w/ stop date
- Localised MSKTopical NSAID first
- Cancer painWHO ladder + palliative input
- Treating red-flag pain as routine
- Ignoring overdose risk
- Not re-examining when pain has changed
- Not assessing function/mood/sedation
- Routine re-imaging without a new indication
- Not calculating the morphine-equivalent dose / reviewing the record
🚩 The wrong paradigm is the problem
Neil's formulation is chronic non-specific low back pain with the features of chronic primary pain, mismanaged with escalating opioids and a gabapentinoid that have worsened his function, mood and risk (compounded by alcohol). The plan: validate; decline escalation; apply NG193 assessment principles with NG59 for the back pain (exercise, with ACT/CBT for pain under NG193 for the chronic-primary-pain features; no opioids, gabapentinoids or antidepressants for the back pain itself); assess his low mood formally and, if he has depression, treat it in its own right — which may include an antidepressant such as duloxetine chosen with the pain in mind; collaboratively and gradually deprescribe the opioids and gabapentinoid with support; treat his mood, sleep and alcohol; set functional goals; provide naloxone and safety-net — never abruptly stopping or abandoning.
- Applying the WHO ladder/opioids to chronic primary pain
- Not naming the right paradigm (NG193)
- Declining opioids without offering the alternative therapies
- Not supporting deprescribing / dependence
Validate — name the request and the distress behind it
Neil's request is logical from where he sits: every previous increase was offered as the answer, and the pain is still there. Behind it sit exhaustion, fear of withdrawal and of not coping, and the experience of not being believed. Naming the request out loud, and the feeling behind it, shows you have heard him before you say anything he does not want to hear.
"You've come in hoping for a stronger dose, because the pain is still wrecking your days even on all these tablets. That makes complete sense — you've been told before that a higher dose was the answer. I believe the pain is real, and I want to help."Explain — share the evidence honestly, in his terms
The key messages: opioids help little in long-term non-cancer pain, and NICE NG59 advises against them for chronic low back pain; towards about 120 mg/day morphine-equivalent, harm rises substantially without extra benefit (local high-dose opioid guidance); the gabapentinoid is not recommended for back pain (NG59); and the combination with alcohol risks stopping his breathing (MHRA). Link the evidence to his own experience — doses have gone up, and his life has got smaller.
"Here's what's become clear over the last few years: for long-term back pain, strong painkillers give very little benefit, and as the dose goes up they can make the nerves more sensitive, sap your energy and mood, and become dangerous with alcohol. Honestly — has each increase given you more life, or less?"Negotiate — offer something real today
A refusal on its own is abandonment. Neil should leave with: a referral for exercise-based rehabilitation (with psychological therapy for pain — ACT or CBT — or a pain-management programme where available), a mood assessment and treatment offer, alcohol support, take-home naloxone and safety advice, an agreed start date and pace for a slow reduction he controls, and a follow-up booked with the same clinician. He sets the pace; you hold the direction.
"I'm not going to increase the dose, and I'm not going to stop anything suddenly either. What I'd like is this: we get you into a programme that actually helps back pain, we look after your mood and sleep, and — when you're ready — we start bringing the tablets down very slowly, with you in charge of the pace. I'll see you again in two weeks. Can we try that together?"Record a baseline (walking distance, activities, sleep hours, PHQ-9, AUDIT-C, total OME) so progress is measured against function, not the pain score. Pain scores often barely change even when life improves — and that is still success.
Graded activity reconditions deconditioned muscles, reduces fear of movement by exposure, improves sleep and mood, and engages descending pain inhibition. "Hurt does not equal harm" becomes a lived experience rather than a slogan.
Refer to physiotherapy / an exercise-based back programme. Start below his current tolerance (pacing), increase by small fixed amounts rather than "until it hurts", and expect flare-ups — plan for them in advance. Choice of exercise matters less than doing it consistently.
A CBT-informed approach addresses catastrophising, fear-avoidance, low mood and unhelpful beliefs about damage, while the physical component rebuilds capacity. ACT helps people pursue valued activities alongside pain rather than waiting for it to go.
Pain-management programme (usually group-based, via the local pain service or MSK service). NHS Talking Therapies can offer psychological support for coexisting depression or anxiety; many services have long-term-condition pathways. Self-management resources such as Live Well with Pain can bridge the wait.
Persistent pain reflects a sensitised nervous system more than ongoing tissue damage — the "over-sensitive alarm". Understanding this reduces threat, fear and the drive to seek stronger drugs, and makes exercise and tapering feel safe.
Use simple analogies (a car alarm that goes off when someone walks past), reassure that normal scans are genuinely good news, and give written or online resources. Revisit at each appointment — one explanation is rarely enough.
Poor sleep lowers pain thresholds and worsens mood; pain and alcohol fragment sleep further. Opioids themselves disturb sleep architecture and can worsen sleep-disordered breathing.
Behavioural approaches first (consistent wake time, limiting daytime naps, stimulus control; digital CBT for insomnia where commissioned). Avoid adding hypnotics — a benzodiazepine or Z-drug on top of opioids and a gabapentinoid is the combination MHRA warns can be fatal.
Alcohol adds to opioid and gabapentinoid respiratory depression, disrupts sleep, worsens mood, and increases paracetamol liver risk. Reducing it is one of the quickest ways to make Neil safer today.
AUDIT-C / AUDIT to quantify; brief intervention; if dependent drinking, refer to the local drug and alcohol service and do not stop alcohol abruptly without assessment (withdrawal risk). UK Chief Medical Officers' low-risk guideline: no more than 14 units a week, spread over three or more days.
Meaningful activity and social connection reduce the salience of pain and improve mood. Returning to some form of work is associated with better health outcomes for most people.
Social prescribing link worker for community activity, peer support or volunteering; employment support services; fit note with adjustments ("may be fit for work taking account of the following advice") if he returns. Frame each step as an experiment, not a test.
- Count the real dose — convert every opioid to total OME using Opioids Aware guidance; ask what he actually takes.
- One drug at a time. Agree an individualised, proportional reduction — for example about 5–10% of the current dose every 2–4 weeks as a starting point, not a fixed rule (NICE NG215) — modified-release/patch first, keeping any immediate-release doses few and countable, with progressively smaller decrements at lower doses.
- Hold, don't reverse at difficult times; never go back up more than one step.
- Pre-warn about withdrawal — sweats, yawning, cramps, restless legs, anxiety, diarrhoea — beginning within hours to days of a cut; duration and severity vary, and during a prolonged taper symptoms can last weeks or months (NICE NG215). Withdrawal and recurrence of the underlying pain can overlap — assess before deciding.
- Gabapentinoid: taper gradually too (withdrawal includes anxiety, insomnia, sweating and, rarely, seizures); do not stop abruptly. Which drug first is a shared decision — the one with least benefit or most harm is a sensible start.
- Loss of tolerance: warn that after a reduction or a gap, returning to his old dose could be fatal.
- No escalation of opioid or gabapentinoid; no new sedatives.
- Take-home naloxone — consider for anyone on high-dose opioids, with CNS-depressant co-prescribing, alcohol misuse or previous overdose (site protocol). Show the family how to use it; it does not replace calling 999.
- Supply controls — one prescriber, one pharmacy, shorter intervals (e.g. weekly or fortnightly) if he runs out early; no early or "lost" replacement scripts without review.
- Alcohol — brief intervention now; never drink with night-time doses.
- Mood and risk — PHQ-9 and a direct suicide question; if risk, limit quantities held at home and involve crisis/mental-health services.
- Laxative — review constipation; stimulant ± osmotic rather than bulk-forming.
- Driving — advise not to drive if drowsy or after dose changes; record it.
"Rub a small amount into the sore joint, as directed on the pack, and wash your hands afterwards. It works best alongside the exercises, not instead of them."
SCA phrase: "For your knee, the safest and most effective tablet-free option is an anti-inflammatory gel — it works locally with far fewer side effects than tablets."
"Take with food, for as short a time as you can. Stop and tell us if you get indigestion, black stools, ankle swelling, or if you're being sick or can't keep fluids down."
SCA phrase: "Before I prescribe an anti-inflammatory I need to check your kidneys, blood pressure and stomach risk — and I'll add a stomach-protecting tablet."
"Check every packet you buy — many cold and flu remedies contain paracetamol too. Never take more than the label or I say, even when the pain is bad."
SCA phrase (Neil): "With the amount you're drinking, I'd want to be careful with paracetamol too — and for long-term back pain it doesn't add much anyway."
"This is for a few days only while the worst settles. It can cause addiction if taken regularly for long. Don't drive if it makes you drowsy, and take the laxative I've given you."
SCA phrase: "I'll give you a small supply with a clear stop date — these are for a short spell, not long term."
"Tramadol is a proper opioid and can cause dependence. It also reacts with some antidepressants, so tell any doctor or pharmacist you're taking it."
SCA phrase: "Tramadol isn't a gentler option — it has the same dependence risks as other opioids plus some of its own, so I wouldn't switch you to it."
"Opioids can cause dependence and addiction even at prescribed doses (MHRA 2020). Never mix with alcohol or sleeping tablets, keep them locked away, never stop suddenly, and return any spares to the pharmacy."
SCA phrase (Neil): "Going higher would add risk without adding relief. What I can offer is a slow, supported way down, alongside the treatments that do help back pain."
"This medicine isn't recommended for back pain, and with your other tablets and alcohol it adds to the risk of slowed breathing. We'll bring it down gradually so you don't get withdrawal."
SCA phrase: "Pregabalin is a nerve-pain medicine — it isn't recommended for back pain, and it's one of the things making your current mix risky."
"This isn't because I think the pain is in your head. These medicines can help sleep, mood and how the nervous system handles pain. It takes a few weeks to judge."
SCA phrase (Neil): "Your mood matters in its own right. If the questionnaire shows depression, an antidepressant is a reasonable option, and some have the bonus of helping with pain."
"This is like a fire extinguisher — I hope it's never needed. If you can't be woken or your breathing is very slow, whoever is with you calls 999 and uses this."
SCA phrase: "Offering naloxone isn't me expecting the worst — it's a standard safety step for anyone on your combination of medicines."
Driving and the law
Driving with certain specified drugs (including morphine) above set blood limits, or while impaired by any drug, is an offence; there is a medical defence if the medicine is taken as directed and driving is not impaired. Advise no driving when drowsy, on starting or changing a dose, during noticeable withdrawal, or after alcohol. Patients do not usually need to tell the DVLA simply because they take prescribed opioids, but must if a medical condition or the medication affects their ability to drive safely (check DVLA guidance).
"On the days after each dose change, or if you feel foggy or drowsy, please don't drive. If you ever feel the tablets affect your driving, you mustn't drive — and we should talk about it."Work and benefits
A taper and a rehabilitation programme can feel like a threat to a benefits claim or to "proof" of disability. Be explicit that the aim is his wellbeing, that fit notes and reports will reflect his condition honestly, and that improvement at his own pace is not a trap. Employment support services and occupational health can help with a phased return.
"Getting you more active isn't about pushing you back to work before you're ready. It's about you getting more of your life back — and when you feel ready, there's support for the next step."Family and carers
The family live with the effects of both the medication (sedation, irritability) and the taper (withdrawal, flare-ups). Involving a partner helps with pacing, storage, naloxone and noticing low mood. Securely store all opioids and gabapentinoids — one opioid tablet can be dangerous to a child.
"Would you like your partner to know the plan? It helps to have someone who understands that a rough few days after a reduction is withdrawal settling, not the pain getting worse."Identity and stigma
Being on opioids can bring stigma — "addict", "drug-seeker" — which patients often feel keenly. Separate physical dependence (an expected effect of long-term use) from addiction, and use neutral language in the notes and at the pharmacy. Neil's identity as someone who worked and was active is a resource to draw on.
"Your body being used to these tablets is a normal effect of taking them for years — it doesn't make you an addict. We'll reduce them carefully because that's how your body stays comfortable."Today — safety and agreement
No dose increase. Total OME recorded. Naloxone supplied and explained. Alcohol brief intervention. PHQ-9, GAD-7 and a direct suicide question. Referrals: exercise-based programme, plus psychological therapy for pain (ACT/CBT) or a pain-management programme; drug and alcohol service if dependent drinking or addiction features. Agree when the taper might start (today or at the next visit) and write down functional goals.
2 weeks — first step
Same clinician. How has he been? First agreed opioid reduction step (e.g. 5–10% of the current dose) and how it was tolerated; withdrawal vs pain explained again. Alcohol, sleep, mood. Any new red flags. Prescription interval and pharmacy confirmed.
Every 2–4 weeks — the taper rhythm
Next step if tolerated; hold if a life event or a bad fortnight, never go back up more than one step. Has the exercise or programme started — what got in the way? Treat depression if confirmed; review any antidepressant. Celebrate function gained (distance walked, activities resumed).
3 months — review the whole plan
Function against baseline; PHQ-9; AUDIT-C; OME now vs start. When the opioid is lower, plan the gabapentinoid reduction (or vice versa). Consider pain service advice if the taper has stalled at a high dose, or drug service if addiction features emerge.
6–12 months and annually
Every analgesic still prescribed has a documented functional benefit. Red flags re-screened. Testosterone if symptoms on long-term opioids. Driving advice re-recorded. Relapse plan for flares that does not involve restarting high-dose opioids.
Memory rule — review every analgesic against "FORMS"
Function gained (the real outcome) · OME total and how he actually takes it · Red flags and risk (new pathology, mood, suicide) · Mixing (alcohol, benzodiazepines, gabapentinoids, OTC codeine) · Side effects (bowels, sedation, falls, hormones).
| Medication / target | Monitor | Timing | Action threshold |
|---|---|---|---|
| Opioids (any) | Total OME; function vs goals; sedation; bowels; early requests | Each taper step; at least 6-monthly once stable | About 50 mg/day OME → heightened review; approaching ~120 mg/day → specialist advice; no functional benefit → agreed, individualised taper; aberrant use → name it, shorter supply intervals, drug service |
| Gabapentinoids | Benefit, sedation, dizziness, falls; eGFR | Each review | Not indicated for back pain → shared plan to taper; reduced eGFR → dose adjustment per SPC |
| Oral NSAIDs | eGFR, BP, GI symptoms, PPI cover | Before starting; periodically if continued | Falling eGFR, uncontrolled BP, GI bleeding signs → stop; ACE inhibitor/ARB + diuretic → avoid or monitor closely |
| Paracetamol | Weight, alcohol intake, LFTs if risk | At prescribing and review | Under 50 kg or hepatotoxicity risk → reduced dose per SPC; not helping → stop the repeat |
| Mood and risk | PHQ-9, GAD-7, direct suicide question | Baseline, each visit during taper | Suicidal ideation → same-day risk assessment, reduce quantities at home, crisis team as needed |
| Alcohol | AUDIT-C / AUDIT | Baseline, 3-monthly | Higher-risk drinking or dependence → brief intervention / specialist referral; assessed withdrawal plan |
| Endocrine (long-term opioids) | Symptoms; testosterone in men | Annually or if symptomatic | Low → endocrine advice and a further reason to taper |
| Red flags | New/changed pain, neurology, weight loss, fever, bladder/bowel/saddle symptoms | Every visit | Cauda equina symptoms → emergency same day; other red flags → urgent assessment per NICE NG12 / local pathways |
- Escalating opioids / abrupt stopping / abandoning the patient
- No non-drug therapies; ignoring mood/sleep/alcohol
- No functional goals / no naloxone / no review
Who you are
Neil Brandon, 49. Four years of chronic low back pain; scans normal; no red flags. You're on increasing opioids (a high dose now) plus a gabapentinoid, and you want a stronger dose because the pain "still doesn't touch it". Despite all the medication you're worse — stopped work and exercise, sleep badly, mood is low, and you drink more than you used to. You're frustrated and feel dismissed by doctors, and frightened you won't cope without more medication. You've never been offered exercise therapy, psychological support, or a proper explanation of your pain.
Hidden concerns (reveal if explored)
Not being believed (main): you feel nobody takes your pain seriously; validation changes everything.
Fear of coping without medication: you're scared of withdrawal and worse pain — reassurance about a slow, supported reduction helps.
Low mood / drinking: you'll admit these if asked compassionately.
Clinical details if asked
- Chronic low back pain 4 years; normal imaging; no red flags (no new severe pain/leg weakness/bladder-bowel change/weight loss/fever)
- High-dose opioids + gabapentinoid; function worse despite them; drowsy at times
- Drinking more than before; low mood, poor sleep; no current plan to harm yourself
- Never offered physio/psychological therapy/pain programme or a clear explanation
Reactions at key moments
- If refused bluntly with no validation/alternative: you get angry/upset, feel dismissed.
- On "your pain is real and not your fault": you soften, feel heard.
- On the honest explanation (opioids don't help long-term pain): sceptical but listen if validated.
- On a supported, slow reduction + real therapies: anxious but willing if not abandoned.
- Challenge line: "So you're refusing to help me and just taking my tablets away?"
Resolution: Neil is well served if the GP: (1) validates that his pain is real and that he's not to blame; (2) names the pain type (chronic primary pain) and explains honestly that escalating opioids/gabapentinoids provide little benefit and cause harm (worsening function/mood, dependence, overdose — heightened by the alcohol and the drug combination); (3) declines to escalate while offering the evidence-based alternatives (NG193 with NG59 for back pain: exercise, return to normal activity, and ACT/CBT for pain under NG193) and treating his mood (an antidepressant if depression is confirmed), sleep and alcohol; (4) plans a gradual, supported, collaborative deprescribing — never abrupt — with functional goals, take-home naloxone and a safety-net, and does not abandon him. He disengages if refused bluntly, abruptly stopped, or left without validation or an alternative.
Nociceptive (acute): WHO ladder, time-limited — paracetamol ± topical/oral NSAID (cautions), short opioid course with a stop date. Neuropathic: amitriptyline/duloxetine/gabapentinoid (not standard analgesics). Chronic primary pain (NG193): exercise, CBT/ACT, acupuncture, consider antidepressant; AVOID opioids/gabapentinoids/NSAIDs/paracetamol. Cancer: WHO ladder + palliative care.
Opioids: little benefit, much harm in chronic non-cancer pain; don't escalate (esp. towards 120mg OME). Gabapentinoids = controlled drugs; never co-prescribe casually with opioids; opioid+gabapentinoid+alcohol = overdose risk → naloxone. Deprescribe gradually, collaboratively, with support; treat mood/sleep/alcohol; set functional goals; re-screen red flags; don't abandon.