Protocol · WHO chronic pain guidance
Chronic pain in adults
Chronic pain is pain that lasts or keeps coming back for more than three months. In most adults with long-term back or musculoskeletal pain, no dangerous disease is found, and the pain is shaped by sleep, mood, work and worry as well as the body. The most helpful care is a clear explanation, staying active, a structured exercise plan and psychological support. Medicines play a smaller part than people expect, and long-term opioids do more harm than good.
- Based on WHO chronic pain guidance
- For doctors, clinical officers, nurses and rehabilitation workers
- Reviewed October 2026
1Who / when
- Adults (including older people) with pain on most days for more than 3 months: back, neck, joints, widespread pain, or nerve pain.
- Chronic primary pain: not explained by another disease or injury (for example most chronic low back pain).
- Chronic secondary pain: due to a disease such as osteoarthritis, diabetes or HIV neuropathy, or cancer. Treat the disease too.
Cancer pain and pain at the end of life: use the palliative symptom protocol, where opioids have a central role.
2Red flags: refer now
Signs that the pain may come from cancer, infection, a fracture or inflammatory disease:
- Past cancer, weight loss, fever, night sweats, or TB contact (spinal TB).
- Pain that is constant, worse at night or at rest, or started after significant injury, or in someone with weak bones.
- New weakness, numbness, or loss of bladder or bowel control (refer the same day).
- A hot, swollen joint, or long morning stiffness in a younger adult (possible inflammatory disease).
3Assess
A thorough biopsychosocial assessment
- Where the pain is, what it feels like, what makes it better or worse; what the person can no longer do.
- Burning, shooting or electric pain with numbness suggests nerve (neuropathic) pain.
- Sleep, mood and worry: screen for depression (mhGAP) and ask about thoughts of self-harm.
- Work, family, money, and what the person believes is causing the pain.
- All medicines, including bought pain tablets, opioids, sedatives, alcohol and herbal remedies.
- Examine the painful area, nerves (power, sensation, reflexes) and general health. Tests only to look for a cause suggested by red flags.
4Classify
| Picture | Classify as | Action |
|---|---|---|
| Any red flag | Possible serious cause | Refer; treat pain meanwhile |
| Burning or shooting pain with numbness; diabetes, HIV or after shingles | Neuropathic pain | Treat the cause; consider amitriptyline |
| Pain with low mood, poor sleep or high distress | Pain with depression or distress | Treat both (mhGAP); psychological support |
| No red flags, no clear disease | Chronic primary pain | Explanation, activity, exercise, psychological support |
5Treat
First: non-drug care (WHO 2023, for chronic low back pain)
- Explain and advise: personalised information; reassure that serious disease is unlikely; stay active and keep working or doing valued activities, increasing step by step.
- Structured exercise programme: suggested for all, including older people.
- Psychological support: cognitive behavioural therapy or operant (activity-based) therapy where available.
- Where available and acceptable: spinal manipulation, massage, acupuncture; a team programme combining physical and psychological care.
- Not recommended routinely: traction, therapeutic ultrasound, TENS, lumbar braces or belts.
Medicines: lowest effective dose, shortest time
- NSAIDs (for example ibuprofen, per national formulary) may be offered for short periods. Avoid or take great care with kidney disease, heart disease, older age, past stomach bleeding or anticoagulants; consider a stomach-protecting medicine.
- Paracetamol is widely used, but evidence of benefit in chronic back pain is lacking; do not exceed 4 g a day.
- Neuropathic pain: amitriptyline at a low dose at night (for example 10 to 25 mg), increased slowly per national formulary; warn about drowsiness, dry mouth and dizziness on standing.
- Not routine for chronic primary low back pain: opioids, tricyclic and SNRI antidepressants, anticonvulsants such as gabapentin, benzodiazepines.
OpioidsNever as the only treatment. If used, the lowest dose for the shortest time, with a clear goal and regular review. Long use can cause dependence, overdose and more pain. Reduce gradually; do not stop suddenly after long use.
6Follow-up
- Agree one or two goals about function (walk to market, return to work), not only pain scores.
- Review regularly, more often at first: activity, mood, sleep, side effects, medicine use. Change the plan if it is not working.
- Stop medicines that are not helping. Review older people for polypharmacy (five or more medicines).
7Counsel
- Long-lasting pain is real, but it rarely means serious damage. Hurt does not always mean harm.
- Keep moving: gentle, regular activity helps more than rest.
- Pace yourself: do a little more each week, even on bad days.
- Sleep, mood and stress affect pain; we can help with these too.
- Flares are common and usually settle; have a plan for them.
Your examination does not show dangerous damage. The pain is real, and the best way to reduce it is to keep active a little more each week. Tablets help a little, but exercise and support help more.
8When to refer
- Same day: new weakness, numbness in the saddle area, or loss of bladder or bowel control.
- Any other red flag, for diagnosis.
- Severe depression, suicidal thoughts, or harmful opioid, sedative or alcohol use (mhGAP).
- Not improving despite a full trial of first-line care, for rehabilitation or multidisciplinary pain care where available.
9Sources
- World Health Organization. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. 2023 (ISBN 9789240081789). ICD-11 definition (more than 3 months); recommendations for education, structured exercise, needling, spinal manipulation, massage, operant therapy, CBT, NSAIDs and multicomponent care; against traction, ultrasound, TENS, braces, opioids, SNRIs, tricyclics, anticonvulsants; Box 1 on paracetamol and benzodiazepines; safe medication and opioid stewardship practice points.
- World Health Organization. WHO guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents. 2018 (ISBN 9789241550390). Amitriptyline typical starting dose 10 to 25 mg at bedtime; paracetamol maximum; gradual opioid reduction.
- World Health Organization. Integrating palliative care and symptom relief into primary health care: a WHO guide for planners, implementers and managers. 2018. Opioids should not be first-line treatment for chronic pain outside cancer, palliative and end-of-life care.
- World Health Organization. mhGAP Intervention Guide, version 2.0. 2016. Assessing depression, self-harm and substance use.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.