General Practice · Full case
Analgesia in Primary Care
Analgesia in Primary Care · Clinical Reasoning Framework v2
GP & SCA · acute vs chronic · nociceptive vs neuropathic vs primary pain · WHO ladder · NICE NG193 · opioid stewardship · deprescribing · the difficult conversation
Name the pain type firstTreatment follows the mechanism: NOCICEPTIVE (tissue damage — responds to paracetamol/NSAID/the WHO ladder), NEUROPATHIC (burning/shooting, allodynia — responds to amitriptyline/duloxetine/gabapentinoids, NOT standard analgesics), or CHRONIC PRIMARY PAIN (pain as the condition itself — NG193). Reaching for "stronger painkillers" without naming the type fails
Acute: WHO ladder, time-limitedFor acute nociceptive pain: step up the WHO ladder — paracetamol ± NSAID (lowest dose/shortest course, gastroprotection & renal/CV caution), then weak then strong opioids for short, defined courses with a stop date. Topical NSAIDs first for localised musculoskeletal pain
🟣 Chronic primary pain (NG193)For chronic primary pain, NICE NG193 recommends AGAINST starting paracetamol, NSAIDs, opioids, gabapentinoids or benzodiazepines — they don't help and cause harm. Offer instead: exercise, CBT/ACT, acupuncture, and (off-label) an antidepressant (e.g. duloxetine/amitriptyline) after shared discussion
Opioids: poor for chronic painOpioids have little benefit in chronic non-cancer pain and substantial harm (dependence, hyperalgesia, falls, overdose, hormonal/immune effects). Avoid escalating; doses above ~120mg morphine-equivalent/day rarely add benefit and increase harm. Review and deprescribe
Gabapentinoids = controlled drugsPregabalin/gabapentin are controlled drugs with misuse/dependence potential, especially with opioids (additive respiratory depression and overdose). Use only for neuropathic pain, review regularly, and never co-prescribe casually with opioids
Deprescribe collaborativelyReducing opioids/gabapentinoids that aren't working is active care — gradual, agreed, with support, addressing the function/mood drivers and the fear of increased pain (withdrawal-mediated). Don't stop abruptly; don't abandon. Set functional goals, not just pain scores
Treat the cause & the personAnalgesia is an adjunct: find and treat the cause, screen red flags, address mood/sleep/function and the biopsychosocial picture. Chronic pain is rarely "fixed" by a tablet; the goal is improved function and quality of life, supported self-management, and realistic expectations
The difficult conversationPatients on long-term opioids who feel they help, and request more, are common and challenging. Validate the pain and distress, avoid blame, explain the evidence honestly, and partner on a plan — coercion or abrupt stopping drives harm and disengagement
A 49-year-old man on escalating opioids for chronic back pain that "still doesn't touch it", asking for a stronger dose — whose function and mood are worsening
📋 Clinical Stem — Analgesia in Primary Care
Neil Brandon, 49, has had chronic low back pain for 4 years with no red flags and normal imaging. He's been on increasing doses of opioids (now a high morphine-equivalent dose) plus a gabapentinoid, and attends asking for a stronger dose because the pain "still doesn't touch it". Despite the medication, his function is worse — he's stopped working and exercising, sleeps badly, and his mood is low. He's frustrated, feels no one takes his pain seriously, and is frightened that without more medication he won't cope. He drinks more than he used to. He's never been offered exercise therapy, psychological support or a clear explanation of his pain.
This stem tests rational analgesia and opioid stewardship: recognising chronic primary/non-cancer back pain where escalating opioids and gabapentinoids provide little benefit and cause harm (worsening function, mood, sleep, dependence, overdose risk — heightened by the alcohol and the opioid+gabapentinoid combination); naming the pain type and applying NICE NG193 (which recommends against these drugs for chronic primary pain and for exercise, psychological therapy and possibly an antidepressant); validating the patient's genuine pain and distress while honestly explaining the evidence; planning a collaborative, gradual deprescribing of opioids/gabapentinoid with support, functional goals, and treatment of the mood/sleep/alcohol drivers; and avoiding both uncritical dose escalation and abrupt, punitive stopping. The SCA challenge is the difficult conversation — declining to escalate, and proposing a different, evidence-based path, without the patient feeling dismissed or abandoned.
Scenario A — Chronic pain, opioid escalation request (this stem) Validate; don't escalate; name the pain type (NG193); offer exercise/psychological therapy ± antidepressant; collaborative deprescribing of opioids/gabapentinoid; treat mood/sleep/alcohol; functional goals.
Scenario B — Acute nociceptive pain WHO ladder, time-limited: paracetamol ± topical/oral NSAID (cautions), short opioid course with a stop date; treat the cause.
Scenario C — Neuropathic pain Burning/shooting/allodynia → amitriptyline/duloxetine/gabapentinoid (not standard analgesics); treat the cause; review.
Scenario D — Cancer / palliative pain Different paradigm — WHO ladder including strong opioids titrated to effect, anticipatory care, specialist palliative support.
Scenario E — Red-flag pain New severe/atypical pain with red flags (cauda equina, fracture, malignancy, infection) → don't just analgese — investigate/refer urgently.
Key variables to adapt for Acute vs chronic; pain type (nociceptive/neuropathic/primary); WHO ladder vs NG193; opioid/gabapentinoid stewardship & deprescribing; high-risk combinations (opioid+gabapentinoid+alcohol); function/mood/sleep drivers; red flags; cancer/palliative paradigm; the difficult conversation & shared decisions.
Steps:
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Step 1
History — Validate & Name the Pain Type · Function/Mood · Meds & Risk · Red Flags · ICE
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The history must validate the pain as real, name the pain type (which determines treatment), assess the impact on function and mood (the real targets), review the current medication and its risks, and screen red flags. Neil's escalating opioids with worsening function is the signature of chronic pain mismanaged with the wrong tools — the consultation's job is to redirect, compassionately.
🎓 SCA framing — validate the pain, redirect the treatment
"I don't doubt your pain is real and exhausting — and I can see the medication isn't giving you your life back. I'm not going to dismiss you. But I'd be doing you a disservice to just add more of something that isn't working and is causing harm. Let me explain a different approach that genuinely helps."
Declining to escalate without validating and offering an alternative will fail. Naming the pain as real, the medication as ineffective/harmful, and proposing an evidence-based path is the skill.
1A — Pain type, function, medication and red flags
1B — Red flags
🚨
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 |
1C — ICE
💭 Ideas
"What do you feel the medication is doing for you — and what do you think would help most?"
Neil believes stronger opioids are the answer and fears coping without them. Surfacing this lets you explore, honestly, whether they're actually helping his function, and to introduce the evidence and a different model of pain without simply contradicting him.
😟 Concerns
"What are you most worried about — the pain, not being believed, or not coping without more medication?"
His concerns — not being taken seriously, and fear of withdrawal/uncontrolled pain — are exactly what derail these consultations. Naming and addressing them (validation, a supported plan, no abandonment) is what makes change possible.
🎯 Expectations
"You came hoping for a stronger dose — can I be honest about why that won't help, and what will?"
He expects dose escalation. Naming this lets you decline it transparently while offering a credible alternative (exercise, psychological therapy, treating mood/sleep, careful deprescribing with support) — so he leaves with a plan, not a refusal.
1D — Psychosocial context
✅ 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."🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills
Key phrases that score
"Is it aching tissue pain, burning nerve pain, or has the pain itself become the problem?" — names the type.
"Does the medication help you DO more, honestly?" — function over score.
"Opioids plus the gabapentinoid plus alcohol is a risky mix — let's keep you safe." — high-risk combination.
Deductions
- 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)
🔴 Red
Escalates opioids; or refuses bluntly with no validation/alternative; pain type/function/risk not assessed; red flags missed
🟠 Amber
Validates; names pain type; declines escalation; some risk assessment; alternatives/deprescribing vague; ICE partial
🟢 Green
Validates & names pain type; function/mood assessed; high-risk combo addressed; declines escalation with NG193 alternatives + supported deprescribing; ICE all three; safety-net
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Step 2
Triage — Red-Flag Pain · Overdose Risk · Acute vs Chronic Pathways
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Triage separates pain that needs urgent investigation (red flags) and the patient at acute overdose risk from the routine acute-vs-chronic analgesic decision.
🔴 Urgent
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
🟠 Chronic
NG193 path
Right tools- Chronic primary painExercise/CBT/antidepressant; NOT opioids/gabapentinoids
- On long-term opioids w/o benefitSupported deprescribing
- NeuropathicAmitriptyline/duloxetine/gabapentinoid
🟢 Acute
WHO ladder
Time-limited- Acute nociceptiveParacetamol ± NSAID; short opioid w/ stop date
- Localised MSKTopical NSAID first
- Cancer painWHO ladder + palliative input
🎓 SCA Checkpoint — Step 2Tasks
Triage rationale
"There's nothing to suggest a new dangerous cause, which is reassuring — so this is long-term pain that needs a different approach than stronger opioids, plus we need to make the current mix safer."
Deductions
- Treating red-flag pain as routine
- Ignoring overdose risk
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Step 3
Examination — Re-examine the Cause · Function · Mood · Sedation/Overdose Signs
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Examination re-checks for a serious or treatable cause (especially if the pain has changed), assesses function and the impact of the pain, and looks for signs of medication harm (sedation, overdose risk) — and screens mood.
🎓 SCA Checkpoint — Step 3TasksGlobal Skills
Narration that scores
"I'll examine your back and legs to make sure nothing's changed or been missed, check how you're moving, and look at how the medication might be affecting you — and ask about your mood and sleep, which really matter in pain."
Deductions
- Not re-examining when pain has changed
- Not assessing function/mood/sedation
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Step 4
Investigations — Only If Indicated · Bloods Before Drugs · Review the Record
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Chronic primary pain rarely needs (re-)investigation; tests are for new red flags, to check organ function before/with analgesics, and to review the prescribing record. Resist re-scanning chronic back pain without a new indication.
🎓 SCA Checkpoint — Step 4Tasks
Key reasoning
"Your scans were normal and nothing's changed to need repeating — re-scanning often finds harmless things that lead to more worry and treatment. I'll check some bloods, look at your prescribing record, and focus on what actually helps."
Deductions
- Routine re-imaging without a new indication
- Not calculating the morphine-equivalent dose / reviewing the record
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Step 5
Formulation — Pain Type → Treatment Paradigm
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The "diagnosis" is the pain type and the right paradigm — matched to the person, their function and their risks.
🚩 The wrong paradigm is the problem
Neil's formulation is chronic primary low back 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 (exercise, psychological therapy, consider duloxetine/amitriptyline after discussion); 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.
🎓 SCA Checkpoint — Step 5Tasks
Explaining the plan
"This is the kind of long-term pain where the painkillers we'd reach for actually don't help and cause harm. The evidence points to movement, support for managing it, and treating your sleep and mood — and slowly easing down the strong medication. I'll set that up and support you through it."
Deductions
- Applying the WHO ladder/opioids to chronic primary pain
- Not naming the right paradigm (NG193)
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Step 6
Referral — Pain Service · Physio/Psychology · Drug Service · Mental Health
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Referral provides the non-drug therapies and the support for deprescribing: physiotherapy/pain-management programmes, psychological therapy, the pain clinic for complex cases, drug services for dependence, and mental-health support — with the GP coordinating.
🎓 SCA Checkpoint — Step 6Tasks
Offering the real treatment
"I'll refer you for physiotherapy and a pain-management programme — the things that actually help — and get you support for your mood and the drinking, and we'll ease the medication down together with help from the team."
Deductions
- Declining opioids without offering the alternative therapies
- Not supporting deprescribing / dependence
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Step 7
Management — Rational Analgesia · Deprescribe with Support · Function Goals · Safety-Net
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Management matches the analgesic to the pain type, declines harmful escalation, deprescribes opioids/gabapentinoids gradually and collaboratively with support, treats the drivers (mood, sleep, alcohol), sets functional goals, provides harm reduction (naloxone) and safety-nets — keeping the patient engaged throughout.
🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills
A plan that scores
"Here's the plan: rather than more opioids, I'll get you physiotherapy and a pain programme, support for your mood and drinking, and we'll ease the strong medication down slowly together — no sudden stops. We'll aim for what you can DO, like getting back to walking and work. I'll give you naloxone for safety, and I'll keep seeing you throughout."
Deductions
- Escalating opioids / abrupt stopping / abandoning the patient
- No non-drug therapies; ignoring mood/sleep/alcohol
- No functional goals / no naloxone / no review
Analgesia in Primary Care — SCA Consultation Scorecard
Name the pain type · WHO ladder vs NG193 · opioid stewardship · deprescribe with support · the difficult conversation
0/ 33 pts
Global Skills
Structure, language, responsiveness
0/7
Tasks
Clinical reasoning, prescribing, management
0/15
Relating to Others
Communication, rapport, shared decisions
0/11
RAG Self-Assessment
🔴 Red
Escalates opioids; OR refuses bluntly/abruptly stops/abandons; pain type/function/risk not assessed; no alternatives; red flags/overdose missed
🟠 Amber
Validates; names pain type; declines escalation; alternatives/deprescribing vague; risk/mood partial; ICE partial
🟢 Green
Validates + names pain type; declines escalation with NG193 therapies + supported deprescribing; high-risk combo + naloxone; treats mood/sleep/alcohol; functional goals; ICE all three; no abandonment
Complete the checklist to see your score and feedback
"Doc, I've come because my back's no better — the tablets still don't touch it. I need a stronger dose. I can't live like this, and nobody seems to take my pain seriously."
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?"
"So you're saying no to a stronger dose and you want to take my tablets off me? Great — another doctor who doesn't believe me and won't help."
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: exercise, psychological therapy, possibly an antidepressant) and treating his mood/sleep/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.
Clinic Quick Reference
Analgesia in Primary Care — Clinical Decision Framework
Pain type · WHO ladder vs NG193 · opioid stewardship
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🔍 1 — Name the pain type
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.
⚖️ 2 — Stewardship & deprescribing
Opioids: little benefit, much harm in chronic non-cancer pain; don't escalate (esp. >120mg MED). 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.
SCA Quick Reference
Analgesia — Consultation Playbook
Validate · name the type · steward opioids · deprescribe with support
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🎯 The three pivots that pass this case
1 · Validate & name the type
The pain is real; name nociceptive vs neuropathic vs chronic primary — treatment follows the type.
2 · Don't escalate opioids
Little benefit, much harm in chronic pain; NG193 = exercise/psychological therapy/antidepressant, not opioids/gabapentinoids. Mind the overdose combo + naloxone.
3 · Deprescribe with support
Gradual, collaborative, never abrupt; treat mood/sleep/alcohol; functional goals; don't abandon.
⛔ Don't escalate opioids for chronic non-cancer pain · Don't refuse bluntly or stop abruptly / abandon the patient · Don't miss the overdose combination (opioid+gabapentinoid+alcohol) — offer naloxone · Don't mask a new red-flag cause as "chronic pain" · Validate, name the pain type, apply NG193, deprescribe with support and functional goals