Analgesics in Chronic Noncancer Pain

Last updated 1 Jun 2026 · Pain & analgesia

📋 Key Information Summary

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Pharmacotherapy is adjunctive — analgesics should support active self-management strategies (exercise, cognitive-behavioural therapy, sleep hygiene) rather than replace them.
Paracetamol (≤ 4 g/day in healthy adults, ≤ 2 g/day with hepatic impairment or low body weight) has limited efficacy in chronic noncancer pain but remains first-line for its safety profile; avoid routine use beyond 3 months without reassessment.
NSAIDs should be used at the lowest effective dose for the shortest duration; always co-prescribe a PPI (e.g., omeprazole 20 mg daily) in patients ≥ 65 years or with GI risk factors.
Topical NSAIDs (diclofenac gel) are preferred over oral NSAIDs for localised musculoskeletal pain — fewer systemic adverse effects, PBS-listed.
Duloxetine (60 mg daily) is first-line adjuvant for chronic musculoskeletal pain, neuropathic pain, and fibromyalgia; amitriptyline (10–75 mg nocte) is a low-cost alternative for neuropathic pain.
Pregabalin (150–600 mg/day in divided doses) and gabapentin (900–3600 mg/day) are PBS Authority Required for neuropathic pain; monitor for sedation, weight gain, and peripheral oedema.
Opioids have no established long-term benefit in chronic noncancer pain and carry significant harms (dependence, overdose, hyperalgesia). Routine initiation is not recommended.
If a time-limited opioid trial (≤ 4 weeks at initiation, maximum 3 months) is considered, use a single low-dose agent with defined functional goals, a signed treatment agreement, and a planned exit strategy.
Codeine ≥ 30 mg per dose is now prescription-only in Australia; combination analgesics (e.g., tramadol + paracetamol) should not be co-prescribed with other opioids or serotonergic agents without careful assessment.
Avoid concomitant benzodiazepines and opioids — this combination markedly increases overdose risk; taper benzodiazepines before or alongside opioid initiation.
Aboriginal and Torres Strait Islander peoples experience higher chronic pain prevalence, earlier onset, and greater severity; culturally safe, multidisciplinary care and access to non-pharmacological treatments are essential.
Regular medication reviews (at least 6-monthly) are mandatory — reassess efficacy, functional outcomes, adverse effects, and the need for continued pharmacotherapy.

Introduction & Australian Epidemiology

Chronic noncancer pain (CNCP) — defined as pain persisting beyond three months or beyond expected tissue-healing time — affects an estimated 3.24 million Australians (16.8% of the adult population) and is the leading cause of disability and reduced quality of life nationally. Back pain, osteoarthritis, neuropathic pain, and fibromyalgia are the most prevalent presentations in primary care.

Analgesic medications have a limited and second-line role in the management of CNCP. The strongest evidence supports non-pharmacological strategies: structured exercise programmes, cognitive-behavioural therapy (CBT), pain neuroscience education, sleep optimisation, and weight management. Where pharmacotherapy is considered, it should be embedded within a biopsychosocial, multidisciplinary framework and targeted to specific pain mechanisms rather than used empirically as monotherapy.

Australian data from the NDSARC (National Drug Strategy Household Survey) and AIHW show that pharmaceutical opioid dispensing has decreased since its 2018 peak, yet opioid-related harms (hospitalisations, deaths) remain disproportionately high, particularly in regional and remote areas. Adjuvant analgesics (duloxetine, pregabalin, amitriptyline) have gained prominence in national and international guidelines as preferred alternatives to opioids for many CNCP presentations.

This article provides an evidence-based, Australian-focused overview of the four major pharmacological classes used in CNCP: paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), adjuvant analgesics, and opioid trials. For each class, recommendations are aligned with the Therapeutic Guidelines (eTG), PBS listings, RACGP guidance, and contemporary systematic reviews.

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No single analgesic is reliably effective for CNCP. The number needed to treat (NNT) for ≥ 50% pain relief is typically 4–7 across all oral analgesic classes. Shared decision-making, realistic goal-setting (function over pain score), and regular review are essential to safe prescribing.

Pain Mechanism	Typical Presentations	First-Line Analgesic
Nociceptive (musculoskeletal)	Osteoarthritis, chronic low back pain, mechanical neck pain	Paracetamol ± topical NSAID; oral NSAID short course
Neuropathic	Diabetic neuropathy, postherpetic neuralgia, radiculopathy, chemotherapy-induced peripheral neuropathy	Duloxetine, amitriptyline, pregabalin, or gabapentin
Nociplastic / Central sensitisation	Fibromyalgia, widespread pain, irritable bowel syndrome overlap	Duloxetine; amitriptyline; non-pharmacological strategies paramount
Mixed	Chronic low back pain with radiculopathy, osteoarthritis with neuropathic component	Combination approach; treat dominant mechanism first

Paracetamol

Paracetamol (acetaminophen) remains the most widely used analgesic in Australia and is often prescribed as first-line for chronic musculoskeletal pain. However, the evidence for meaningful efficacy in CNCP — particularly chronic low back pain and osteoarthritis — is weak. A landmark 2016 Lancet individual patient data meta-analysis found paracetamol was no more effective than placebo for low back pain and only marginally superior for osteoarthritis, with effects below the minimum clinically important difference.

Despite limited efficacy, paracetamol retains a role as a component of multimodal analgesia due to its favourable safety profile at therapeutic doses and its additive effect when combined with other agents. It should not be continued indefinitely without documented benefit.

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Paracetamol

Panadol®, Panamax®, Dymadon® · Analgesic–antipyretic

Adult dose 500–1000 mg PO every 4–6 hours; maximum 4 g/day (≥ 50 kg body weight)

Reduced dose ≤ 2 g/day if body weight < 50 kg, hepatic impairment, chronic alcohol use, or frail elderly

Paediatric dose 15 mg/kg per dose PO/PR every 4–6 hours; max 60 mg/kg/day (4 doses/day)

Route Oral, rectal (not available IV on PBS for CNCP)

Duration Reassess at 4 weeks; do not continue beyond 3 months without documented benefit

Renal adjustment eGFR 10–50 mL/min: extend interval to every 6 hours; eGFR < 10: avoid or use with caution

Hepatic adjustment Max 2 g/day in hepatic impairment; avoid in severe liver disease (Child-Pugh C)

Key adverse effects Hepatotoxicity at supratherapeutic doses; GI bleeding (rare at standard doses); association with cardiovascular events debated but unconfirmed

PBS status ✔ PBS General Benefit

Evidence Summary

Chronic low back pain: No clinically meaningful benefit over placebo (Machado 2016, Lancet). NNT > 20 for ≥ 50% pain relief.
Osteoarthritis (knee/hip): Statistically significant but clinically marginal benefit (mean difference ≈ 3 mm on a 100 mm VAS). NNT ≈ 16 (Brandt 2010).
Combination with other agents: Paracetamol + codeine or tramadol provides modest additive analgesia but increases adverse effects; risk–benefit must be discussed.

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Hepatotoxicity risk: The maximum daily dose of 4 g/day must not be exceeded. Patients should be counselled to check all concurrent medications for hidden paracetamol (e.g., cold and flu preparations, combination codeine products). In patients with chronic alcohol use disorder (≥ 3 standard drinks/day), the daily maximum should be reduced to 2 g/day.

Practical Prescribing Tips

Use a time-contingent dosing schedule (e.g., 1 g TDS) rather than PRN dosing to maintain steady analgesic levels.
Do not combine regular paracetamol with combination products containing paracetamol (e.g., Panadeine Forte, Tramal + paracetamol).
Paracetamol modified-release (665 mg SR, e.g., Panadol Osteo®) is PBS-listed and taken as 6 tablets (3.99 g) once daily; may improve adherence but no additional efficacy.
Document a trial of paracetamol as a prerequisite before escalating to opioids in many formularies and chronic pain service referral criteria.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs are the most effective oral analgesics for inflammatory and nociceptive CNCP, particularly osteoarthritis and chronic tendinopathies. Their mechanism — inhibition of cyclooxygenase (COX-1 and COX-2) enzymes — reduces prostaglandin-mediated inflammation and peripheral sensitisation. However, their use in CNCP is constrained by significant adverse effect profiles including gastrointestinal ulceration and bleeding, cardiovascular events, renal impairment, and hypertension.

Australian guidelines recommend using NSAIDs at the lowest effective dose for the shortest possible duration. Topical formulations are preferred for localised pain. Oral NSAIDs should be reserved for patients with inadequate response to paracetamol and topical agents, and should be co-prescribed with gastroprotection when indicated.

Low GI Risk

Age < 65, no GI history

No additional risk factors for NSAID-related GI bleeding. Short course (≤ 2 weeks) of oral NSAID without PPI is acceptable.

Setting: GP management

Moderate GI Risk

Age ≥ 65, or 1 risk factor

History of dyspepsia, concurrent corticosteroid/anticoagulant use, H. pylori (treat before NSAID). Co-prescribe PPI.

Setting: GP + gastroenterology consideration

High GI / CV Risk

Prior GI bleed, CV disease, CKD stage ≥ 3

Avoid oral NSAIDs if possible. If essential: celecoxib + PPI, shortest duration, close monitoring. Consider specialist review.

Setting: Specialist co-management

Oral NSAIDs

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Naproxen

Naprosyn®, Inza® · Non-selective NSAID (COX-1/COX-2)

Adult dose 250–500 mg PO BD with food; max 1000 mg/day

Duration Shortest effective course; reassess at 2–4 weeks. Consider intermittent use.

Renal adjustment eGFR < 30 mL/min: avoid if possible

Hepatic adjustment Child-Pugh B: reduce dose; avoid in C

CV risk Lower CV risk than diclofenac; preferred non-selective option in CV patients who require an NSAID

PBS status ✔ PBS General Benefit

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Celecoxib

Celebrex® · Selective COX-2 inhibitor

Adult dose 100–200 mg PO daily or BD; max 400 mg/day

Duration Shortest effective course; reassess at 2–4 weeks

Renal adjustment eGFR < 30 mL/min: avoid

Key advantages Lower GI bleeding risk than non-selective NSAIDs; may be combined with low-dose aspirin + PPI in CV patients requiring NSAID

Key adverse effects Sulfonamide allergy cross-reactivity (caution in sulfa allergy); fluid retention; CV risk at high doses (≥ 400 mg/day)

PBS status ✔ PBS General Benefit

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Ibuprofen

Nurofen®, Brufen® · Non-selective NSAID

Adult dose 200–400 mg PO TDS with food; max 1200 mg/day (OTC) or 2400 mg/day (prescription)

Duration Shortest effective course; OTC use ≤ 3 days without medical review

Renal adjustment eGFR < 30 mL/min: avoid

Key notes Lowest GI risk of non-selective NSAIDs at OTC doses; widely available OTC — counsel patients about cumulative NSAID exposure

PBS status ✔ PBS General Benefit (prescription doses)

Topical NSAIDs

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Diclofenac sodium gel 1%

Voltaren Emulgel® · Topical NSAID

Adult dose 2–4 g applied to affected area QID (up to 16 g/day per joint); massage gently into skin

Indication Osteoarthritis of superficial joints (knee, hand, ankle); soft tissue injuries

Key advantages Minimal systemic absorption; 10× lower GI bleed risk than oral NSAIDs; can be used in patients with CKD or CV disease

Key adverse effects Local skin irritation; avoid on broken skin or under occlusive dressings

PBS status ✔ PBS General Benefit

Gastroprotection

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Omeprazole

Losec®, Maxor® · Proton pump inhibitor

Dose for gastroprotection 20 mg PO daily, taken 30 minutes before breakfast

Indication All patients ≥ 65 years on oral NSAIDs; all patients with prior GI bleed on any NSAID; moderate-risk patients on oral NSAIDs

Duration Continue for duration of NSAID therapy + 2 weeks after cessation

PBS status ✔ PBS General Benefit

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Triple whammy: Concurrent use of an NSAID + ACE inhibitor/ARB + diuretic dramatically increases the risk of acute kidney injury. If this combination is clinically unavoidable, check baseline renal function, recheck UEC at 1–2 weeks, and use the lowest NSAID dose for the shortest duration possible.

NSAID Monitoring Checklist

Blood pressure check at initiation and 2 weeks
UEC (renal function) at baseline, 2 weeks, then 3-monthly if ongoing
FBC if prolonged use (> 3 months) — monitor for anaemia from GI blood loss
LFTs at baseline if using diclofenac; repeat at 4–8 weeks
Assess concomitant medications: anticoagulants, antiplatelets, corticosteroids, SSRIs (all increase GI bleed risk), methotrexate (reduced clearance)
Review need for ongoing NSAID at each consultation — aim for intermittent rather than continuous use

Adjuvant Analgesics

Adjuvant analgesics are medications whose primary indication is not pain but which have demonstrated efficacy in specific chronic pain conditions. They are the cornerstone of pharmacotherapy for neuropathic pain, fibromyalgia, and central sensitisation syndromes, and are increasingly preferred over opioids for many CNCP presentations. Selection should be guided by the underlying pain mechanism, comorbidities (particularly depression and anxiety), and side-effect profile.

SNRIs (Serotonin–Noradrenaline Reuptake Inhibitors)

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Duloxetine

Cymbalta® · SNRI

Adult dose 30 mg PO daily for 1 week, then 60 mg PO daily; max 120 mg/day (rarely needed for pain)

Indications (PBS) Diabetic peripheral neuropathic pain; chronic musculoskeletal pain; fibromyalgia; major depression with comorbid pain

Key advantages Treats comorbid depression/anxiety; once-daily dosing; no sedation at standard doses; evidence for multiple pain types

Key adverse effects Nausea (30%, usually transient); dry mouth; constipation; insomnia; dose-dependent hypertension; hepatic risk in alcohol use

Renal adjustment eGFR < 30 mL/min: avoid

Hepatic adjustment Avoid in hepatic impairment

PBS status Restricted Benefit — Authority required for diabetic neuropathic pain

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Venlafaxine

Effexor XR® · SNRI

Adult dose 37.5 mg PO daily × 1 week, titrate to 75–150 mg PO daily (extended-release); max 225 mg/day

Key notes Alternative to duloxetine; less specific evidence for neuropathic pain but widely used. NRI activity (noradrenaline reuptake) requires ≥ 150 mg/day — lower doses are primarily serotonergic.

Key adverse effects Discontinuation syndrome (more severe than duloxetine — taper over ≥ 2 weeks); dose-dependent hypertension; nausea

PBS status ✔ PBS General Benefit (for depression — pain indication is off-label)

Anticonvulsants (Gabapentinoids)

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Pregabalin

Lyrica® · Gabapentinoid (α2δ ligand)

Adult dose 75 mg PO BD (start), titrate by 75 mg BD every 3–7 days; target 150–300 mg BD; max 600 mg/day

Indications Neuropathic pain (diabetic, postherpetic, spinal cord injury); fibromyalgia

Key advantages Rapid onset (days, not weeks); anxiolytic properties; useful in comorbid generalised anxiety disorder

Key adverse effects Dose-dependent sedation, dizziness, peripheral oedema, weight gain; cognitive impairment in elderly; misuse potential (S8 in some states)

Renal adjustment eGFR 30–60: max 300 mg/day; eGFR 15–30: max 150 mg/day; eGFR < 15: 75 mg daily

PBS status Restricted Benefit — Authority required for neuropathic pain

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Gabapentin

Neurontin® · Gabapentinoid (α2δ ligand)

Adult dose 300 mg PO daily (day 1), 300 mg BD (day 2), 300 mg TDS (day 3); titrate to 300–600 mg TDS; max 3600 mg/day

Key notes Non-linear absorption — bioavailability decreases at higher single doses. TDS dosing essential at higher doses. Lower cost than pregabalin.

Renal adjustment eGFR 30–59: max 1200 mg/day; eGFR 15–29: max 600 mg/day; eGFR < 15: max 300 mg/day

PBS status Restricted Benefit — Authority required for neuropathic pain

Tricyclic Antidepressants (TCAs)

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Amitriptyline

Endep®, Amitrip® · Tertiary amine TCA

Adult dose (pain) 10 mg PO nocte (start), titrate by 10 mg every 1–2 weeks; target 25–75 mg nocte; max 150 mg/day (pain doses typically < antidepressant doses)

Indications Neuropathic pain (first-line per eTG); fibromyalgia; chronic headache prophylaxis; comorbid depression/insomnia

Key advantages Low cost; once-daily nocte dosing; addresses comorbid insomnia; decades of clinical experience

Key adverse effects Anticholinergic effects (dry mouth, constipation, urinary retention); sedation; weight gain; cardiac conduction delays (QTc prolongation); falls risk in elderly

Contraindications Recent MI; cardiac conduction defects; concurrent MAOIs; within 2 weeks of fluoxetine cessation

Paediatric dose Not recommended for pain in children; specialist use only for neuropathic pain

PBS status ✔ PBS General Benefit

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Nortriptyline

Allegron® · Secondary amine TCA

Adult dose (pain) 10–25 mg PO nocte (start), titrate to 50–100 mg nocte

Key notes Better tolerated than amitriptyline (less anticholinergic and sedating); active metabolite of amitriptyline. Preferred in elderly.

PBS status ✔ PBS General Benefit

Other Adjuvant Agents

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Topical capsaicin 0.025–0.075%

Zostrix® · TRPV1 receptor agonist (counter-irritant)

Adult dose Apply to affected area TDS–QID; effect builds over 1–2 weeks with regular use

Indication Peripheral neuropathic pain (postherpetic neuralgia, diabetic neuropathy); OA of hands/knee

Key adverse effects Burning sensation at application site (resolves with continued use); avoid contact with eyes and mucous membranes; wash hands after application

PBS status ✘ Not PBS listed (available OTC)

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Lidocaine 5% medicated plasters

Versatis® · Topical anaesthetic

Adult dose Apply up to 3 plasters to affected area for 12 hours on / 12 hours off

Indication Localised neuropathic pain (postherpetic neuralgia); localised musculoskeletal pain

Key advantages Minimal systemic absorption; no drug interactions; can be used in patients unable to tolerate oral agents

PBS status Restricted Benefit — Authority required for postherpetic neuralgia

Adjuvant Selection by Pain Type

Pain Condition	First-Line Adjuvant	Second-Line	Notes
Diabetic peripheral neuropathy	Duloxetine 60 mg daily	Pregabalin, gabapentin, amitriptyline	PBS authority for duloxetine requires documented diabetes
Postherpetic neuralgia	Pregabalin or gabapentin	Amitriptyline, lidocaine plaster, capsaicin	Consider combination therapy for refractory cases
Fibromyalgia	Duloxetine 60 mg daily	Amitriptyline 10–25 mg nocte, pregabalin	Exercise is the strongest evidence-based intervention
Chronic low back pain (neuropathic component)	Duloxetine or amitriptyline	Pregabalin, gabapentin	Gabapentinoids less effective for non-neuropathic LBP
Osteoarthritis (nociceptive)	Paracetamol + topical NSAID (no adjuvant indicated)	Duloxetine (evidence limited)	Adjuvants generally not first-line for pure nociceptive pain

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Combining adjuvants: Duloxetine and amitriptyline may be combined cautiously if the patient has comorbid depression and neuropathic pain poorly responsive to either alone — but serotonin syndrome risk increases. Do NOT combine two serotonergic agents at maximum doses. Monitor for agitation, hyperthermia, clonus, and neuromuscular rigidity.

Opioid Trials

The role of opioids in chronic noncancer pain is extremely limited. High-quality evidence (the SPACE trial, the OPAL trial, and multiple Cochrane reviews) consistently demonstrates that opioids provide modest short-term analgesia in CNCP but no established long-term benefit and carry significant harms including opioid use disorder, overdose death, opioid-induced hyperalgesia, endocrine dysfunction, immunosuppression, falls, and fractures.

Australian guidelines (RACGP, Faculty of Pain Medicine ANZCA, eTG) recommend against the routine initiation of opioids for CNCP. Where a trial is considered after exhaustion of non-pharmacological and non-opioid pharmacological strategies, a structured, time-limited approach with explicit exit criteria is mandatory.

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Do not initiate opioids for chronic noncancer pain as a default prescribing strategy. Opioids should only be considered when: (1) non-pharmacological strategies have been trialled; (2) paracetamol, NSAIDs, and adjuvant analgesics have failed or are contraindicated; (3) there is a clear, time-limited trial plan with defined functional goals; and (4) the patient provides informed consent via a treatment agreement.

Criteria for Opioid Trial Consideration

Documented Failure of Alternatives

At least 2 non-opioid analgesics at adequate dose/duration have been trialled. Non-pharmacological strategies (exercise, CBT/psychology, physiotherapy) have been engaged or offered.

Assess for Opioid Risk

Screen with Opioid Risk Tool (ORT) or equivalent. Assess for: history of substance use disorder (including alcohol), current benzodiazepine or gabapentinoid use, mental health conditions (depression, PTSD), sleep apnoea, respiratory disease.

Treatment Agreement

Signed opioid treatment agreement covering: single prescriber, single pharmacy, defined goals (function, not pain elimination), random urine drug screening consent, agreement not to drive if impaired, acknowledgement of dependence risk.

Time-Limited Trial

Initial trial: ≤ 4 weeks. If functional improvement documented, extend to a maximum of 3 months. Reassess at every visit. If no functional improvement by 4 weeks, taper and cease — do not escalate.

Opioid Selection for Trials

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Tapentadol

Palexia® · MOR agonist + NRI (mu-opioid receptor agonist / noradrenaline reuptake inhibitor)

Adult dose (CNCP trial) 50 mg PO BD (start), titrate to 100 mg BD after 1 week if tolerated; max 500 mg/day

Key advantages Dual mechanism may benefit patients with mixed nociceptive–neuropathic pain; potentially better GI tolerability than traditional opioids; Schedule 8

Key adverse effects Nausea, dizziness, constipation, somnolence; serotonin syndrome risk with SSRIs/SNRIs/MAOIs — avoid combination with tramadol or other serotonergic opioids

Renal adjustment eGFR < 30 mL/min: max 50 mg BD; avoid in eGFR < 15

Hepatic adjustment Avoid in severe hepatic impairment

PBS status Restricted Benefit — Authority required

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Tramadol

Tramal® · Weak MOR agonist + SNRI

Adult dose (CNCP trial) 50 mg PO daily–BD (start), titrate to 50 mg TDS–QID; max 400 mg/day; SR formulation available (100–200 mg BD)

Key advantages Lower abuse potential than full agonist opioids (but still S4/8); modest SNRI activity may benefit neuropathic component

Key adverse effects Nausea (common); dizziness; constipation; seizures (dose-dependent, avoid in epilepsy); serotonin syndrome (avoid with SSRIs, SNRIs, MAOIs, triptans)

Renal adjustment eGFR < 30 mL/min: extend interval to every 12 hours; max 200 mg/day

Hepatic adjustment Avoid in severe hepatic impairment

PBS status ✔ PBS General Benefit

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Oxycodone (low-dose only for trials)

Endone®, OxyNorm® · Full mu-opioid receptor agonist

Adult dose (CNCP trial) 2.5–5 mg PO every 4–6 hours PRN; max 20 mg/day in trial period; aim to avoid regular dosing

Key notes Only if tramadol and tapentadol are contraindicated or ineffective. Higher dependence risk. Do NOT use extended-release formulations for initial trials.

Key adverse effects Respiratory depression; constipation (prophylactic laxative mandatory — e.g., macrogol); nausea; sedation; dependence; opioid-induced hyperalgesia with prolonged use

PBS status Restricted Benefit — Authority required for chronic pain

Monitoring During Opioid Trials

Parameter	Frequency	Action if Abnormal
Functional goals (e.g., return to work, physical activity, ADLs)	Every consultation (minimum 2-weekly during trial)	No functional improvement at 4 weeks → taper and cease; do not escalate dose
Pain score (NRS 0–10)	Every consultation	Track trends; focus discussion on function, not pain scores alone
Adverse effects (constipation, sedation, nausea)	Every consultation	Prophylactic laxative mandatory; dose reduction if persistent sedation
Urine drug screening	Baseline, then random (at least once during trial)	Unexpected substances → referral to addiction medicine; absence of prescribed opioid → non-adherence or diversion
PDMP (SafeScript / QScript / NSPMOS)	Before each prescription	Multiple prescribers or pharmacies → discussion with patient; consider structured prescribing
Driving assessment	At initiation and dose changes	Advise not to drive if impaired; document advice; state-specific requirements (e.g., VicRoads notification threshold)
Mental health screening (PHQ-9, GAD-7)	Baseline and 4-weekly	Worsening mood/anxiety → address before continuing opioids; consider psychological referral

When to Cease and Taper Opioids

No functional improvement after 4-week trial
Dose escalation beyond agreed maximum without clear clinical rationale
Evidence of aberrant behaviour (early refills, lost scripts, multiple prescribers)
Development of opioid use disorder — refer to addiction medicine / OTP
Patient request
Significant adverse effects (endocrine dysfunction, recurrent falls, respiratory events)

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Tapering schedule: Reduce by 10–25% every 1–2 weeks for patients on opioids ≤ 90 mg oral morphine equivalent daily (OMED). For doses > 90 mg OMED, reduce by 10% every 2–4 weeks. Do not abruptly cease opioids. Provide written tapering plan and schedule follow-up within 1–2 weeks of each dose reduction. Consider referral to a pain specialist or addiction medicine specialist for complex tapers.

Opioids and Benzodiazepines — The Dangerous Combination

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Concomitant opioid and benzodiazepine use doubles the risk of overdose death. Australian coronial data consistently identifies this combination as the leading cause of pharmaceutical opioid-related mortality. If a patient is on regular benzodiazepines, taper the benzodiazepine first (or concurrently) before initiating an opioid trial. Never initiate an opioid while the patient is on stable, non-tapering benzodiazepine therapy.

Pathophysiology — Why Different Analgesics Work for Different Pain

Understanding the dominant pain mechanism in an individual patient is essential for rational analgesic selection. Chronic pain is increasingly recognised as a heterogeneous condition involving peripheral nociception, peripheral and central sensitisation, impaired descending inhibition, and psychological amplification.

Mechanism	Pathophysiology	Clinical Clues	Rational Analgesic Target
Peripheral nociception	Tissue damage → prostaglandin release → peripheral nerve stimulation	Pain localised to joint/tissue; improves with rest; visible inflammation	NSAIDs, paracetamol, topical agents
Peripheral sensitisation	Upregulation of sodium channels, TRPV1 receptors; lowered activation threshold	Allodynia, hyperalgesia at site of injury; burning or tingling at periphery	Topical lidocaine, capsaicin, topical NSAIDs
Central sensitisation	Spinal cord wind-up; NMDA receptor activation; glial cell activation; loss of descending inhibition	Widespread pain; disproportionate to findings; poor response to peripherally-acting analgesics; fatigue, sleep disturbance, cognitive dysfunction	SNRIs (duloxetine), TCAs (amitriptyline), gabapentinoids; CBT; exercise
Neuropathic	Nerve injury or disease → ectopic nerve firing; loss of inhibitory interneurons	Burning, shooting, electric shock-like; dermatomal distribution; neurological signs (numbness, weakness)	Duloxetine, amitriptyline, pregabalin, gabapentin; topical lidocaine
Nociplastic	Altered pain processing without tissue damage or nerve lesion; amplified sensory signalling	Fibromyalgia; widespread pain; tender points; associated features (IBS, headache, TMJ, fatigue)	Duloxetine, amitriptyline, pregabalin; non-pharmacological strategies paramount

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Opioids and central sensitisation: Paradoxically, prolonged opioid use can worsen central sensitisation through opioid-induced hyperalgesia (OIH) — a phenomenon whereby opioid exposure increases pain sensitivity via NMDA receptor upregulation and dynorphin system activation. This is one of the key reasons opioids should not be used long-term in CNCP.

Investigations

Investigations in CNCP serve to exclude treatable causes, establish baseline parameters before pharmacotherapy, and monitor for adverse effects. There is no single test that confirms or quantifies chronic pain severity.

Baseline Investigations Before Initiating Analgesics

Essential Full blood count (FBC) Baseline before NSAIDs (monitor for GI blood loss anaemia); exclude haematological causes of pain (e.g., sickle cell, myeloma if suspicious)

Essential Urea, electrolytes, creatinine (UEC) Baseline renal function — determines dosing of paracetamol, NSAIDs, gabapentinoids, duloxetine; monitor for NSAID nephrotoxicity

Essential Liver function tests (LFTs) Baseline before paracetamol (chronic high-dose), duloxetine, diclofenac; exclude hepatic cause of pain

Available HbA1c If neuropathic pain suspected — diagnose or monitor diabetic peripheral neuropathy (MBS item 66837)

Available ESR / CRP If inflammatory aetiology suspected (e.g., new-onset joint pain, morning stiffness > 30 min); screen for inflammatory arthritis

Available Serum B12, folate, TSH If neuropathy — exclude B12 deficiency (particularly in metformin users, elderly, vegans) and hypothyroidism as reversible causes

Available Urine drug screen (UDS) Baseline before opioid trial; random screens during trial; may include immunoassay for opioids, benzodiazepines, cannabis, amphetamines

Specialist Nerve conduction studies / EMG If peripheral neuropathy suspected but aetiology unclear; referral to neurologist or clinical neurophysiology

Specialist MRI lumbar spine / affected region Red flags present (progressive neurological deficit, cauda equina features, malignancy history); avoid in non-specific low back pain without red flags

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MBS items relevant to chronic pain investigations: FBC (65060), UEC (66503), LFTs (66515), HbA1c (66837), CRP (66542), ESR (65140), serum B12 (66825). Nerve conduction studies require specialist referral (neurologist, rehabilitation physician, or clinical neurophysiologist).

Special Populations

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Pregnancy & Breastfeeding

Paracetamol Safest analgesic in pregnancy. Use at lowest effective dose for shortest duration. Category A (TGA).

NSAIDs Avoid in third trimester (risk of premature closure of ductus arteriosus, oligohydramnios). Short-term use in first/second trimester acceptable if essential. Ibuprofen preferred. Category C (TGA).

Duloxetine Avoid in pregnancy — neonatal withdrawal, respiratory distress. Category B3. Compatible with breastfeeding (low transfer).

Amitriptyline Compatible with breastfeeding at doses ≤ 75 mg/day. Limited pregnancy data — generally avoid if possible; category C.

Pregabalin Avoid in pregnancy (preliminary signal for teratogenicity). Category B3.

Opioids Avoid if possible. Codeine and tramadol contraindicated in breastfeeding (CYP2D6 ultrarapid metaboliser risk → neonatal respiratory depression). If opioid essential, morphine or oxycodone preferred; paediatrician monitoring for neonatal abstinence.

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Paediatrics

Paracetamol 15 mg/kg per dose QID; max 60 mg/kg/day. First-line for musculoskeletal pain in children. Adequate evidence in juvenile idiopathic arthritis.

Ibuprofen 5–10 mg/kg per dose TDS; max 30 mg/kg/day (or 1200 mg/day in adolescents). Short-term use for flares.

Gabapentinoids Limited paediatric data. Pregabalin: not TGA-approved < 18 years for pain. Gabapentin: specialist use only (e.g., Complex Regional Pain Syndrome).

Amitriptyline Specialist-initiated for neuropathic pain or functional abdominal pain. Paediatric dose: 0.1–0.5 mg/kg nocte (start low, go slow).

Opioids Avoid for chronic noncancer pain in children and adolescents. Refer to paediatric chronic pain service (e.g., RCH Melbourne, CHW Sydney).

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Elderly (≥ 65 Years)

General principles Start low, go slow. Increased sensitivity to all analgesics. Reduced renal clearance (estimate GFR — do not rely on serum creatinine alone). Higher falls risk with TCAs, gabapentinoids, opioids.

Paracetamol Max 3 g/day (some guidelines recommend 2 g/day in frail elderly). Modified-release formulation may improve adherence.

NSAIDs Avoid if possible. If essential: lowest dose, shortest duration, mandatory PPI co-prescription, renal monitoring. Avoid diclofenac (hepatotoxicity). Naproxen + PPI preferred if NSAID unavoidable.

Amitriptyline Prefer nortriptyline (less anticholinergic burden). Start 5–10 mg nocte. Falls risk, constipation, urinary retention, cognitive impairment — assess Beers criteria. Avoid in cognitive impairment.

Gabapentinoids Pregabalin: start 25 mg BD. Dose-dependent sedation, peripheral oedema, falls. Renal dose adjustment essential.

Opioids Avoid if possible. If essential: reduce dose by 50% (e.g., tramadol 25 mg BD start). Prophylactic laxative. Monitor for sedation, falls, respiratory depression. Driving assessment mandatory.

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Renal Impairment

Paracetamol Safe in CKD stages 1–4. Dose reduction (≤ 2 g/day) in eGFR < 15 or dialysis. First-line analgesic in CKD.

NSAIDs Avoid in eGFR < 30. Contraindicated in nephrotic syndrome, renal transplant (risk of graft dysfunction). If eGFR 30–60: use with extreme caution, monitor UEC at 1 week.

Pregabalin Requires dose reduction (see dosing table above). Dialysable — dose after haemodialysis if on HD.

Gabapentin Significant renal clearance — dose adjustment mandatory. Preferred over pregabalin for more precise dose titration in CKD.

Duloxetine Avoid in eGFR < 30 mL/min.

Opioids Avoid morphine (active metabolite M6G accumulates). Tramadol: extend interval. Oxycodone: preferred if opioid essential (less renally-excreted metabolites). Fentanyl: safest in dialysis patients if parenteral opioid required.

🫁

Hepatic Impairment

Paracetamol Max 2 g/day in chronic liver disease (Child-Pugh A/B). Avoid in Child-Pugh C. First-line when used cautiously.

NSAIDs Avoid in Child-Pugh B/C (coagulopathy, fluid retention, hepatorenal risk). Use with caution in A.

Duloxetine Avoid in hepatic impairment (hepatotoxicity reported).

Amitriptyline Use with caution; cholestatic jaundice reported. Dose reduction recommended.

Opioids Avoid in Child-Pugh B/C. Reduced hepatic clearance of most opioids. Morphine clearance reduced 50%. If essential, start at 50% dose and titrate slowly.

🛡️

Immunocompromised

General considerations Higher infection risk with invasive procedures (e.g., epidural steroid injections). NSAIDs may mask febrile response. Drug interactions with immunosuppressants are common — check interactions with cyclosporine, tacrolimus, and methotrexate (NSAIDs reduce clearance).

Opioids Opioids are immunosuppressive — consider this in patients already on immunosuppression. Morphine has the greatest immunosuppressive effect; fentanyl and buprenorphine have the least.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander peoples experience a significantly higher burden of chronic noncancer pain than non-Indigenous Australians — prevalence estimates range from 25% to 40% in some communities, with earlier onset, greater severity, and more widespread pain phenotypes. The AIHW reports that chronic pain is among the top contributors to the health gap for Indigenous Australians.

Key factors contributing to the pain burden include higher rates of musculoskeletal conditions, diabetes-related neuropathy, injury, rheumatic heart disease, renal disease, and the cumulative physiological impact of socioeconomic disadvantage and intergenerational trauma. Access to non-pharmacological pain management (physiotherapy, psychology, pain medicine specialists) is profoundly limited in remote and very remote areas, where up to 40% of Indigenous Australians reside.

Access to specialist services

Pain medicine specialists, psychologists, and physiotherapists are concentrated in major cities. Telehealth (MBS items 99200–99215) has improved access since 2020 but remains underutilised. Indigenous liaison officers and Aboriginal health workers can support engagement with telehealth pain services.

Cultural safety in pain assessment

Western pain scales (NRS, VAS) may not capture the holistic impact of pain in Indigenous conceptualisations of health. Use culturally validated tools where available; engage Aboriginal health workers/Aboriginal health practitioners in pain assessment. Recognise the social and cultural determinants of pain (family obligations, Country, spirituality).

Medication access in remote areas

Remote Area Aboriginal Health Services (RAAHS) may stock limited formularies. PBS Section 100 (Closing the Gap) co-payment applies — eligible patients pay a reduced or zero co-payment. Ensure medications prescribed are available at the local health service or through Patient-Assisted Transport (PAT). Cold-chain storage for some formulations may be unreliable.

Opioid prescribing disparities

Indigenous Australians are disproportionately represented in opioid-related harm statistics. Pharmacist-delivered opioid stewardship programmes and real-time monitoring (SafeScript, QScript) should be actively utilised. Avoid long-term opioid prescribing without structured monitoring; support transition to non-pharmacological and adjuvant-based strategies.

Multidisciplinary and holistic care

Integrate pain management within existing Aboriginal Community Controlled Health Services (ACCHS). Coordinate with Indigenous Allied Health Australia (IAHA) practitioners. Support Yarning-based approaches to pain education. Involve family and community Elders in treatment planning where appropriate and desired by the patient.

Comorbidity management

Higher rates of diabetes (diabetic neuropathy), chronic kidney disease (NSAIDs and gabapentinoid dose adjustment critical), rheumatic heart disease (NSAIDs for ARF/JIA), and substance use disorders. Screen and manage comorbidities concurrently. Refer to RHDAustralia guidelines for co-management with alcohol and other drug services.

✅

Closing the Gap PBS co-payment: Eligible Aboriginal and Torres Strait Islander patients with, or at risk of, chronic disease can access PBS medicines at a reduced or zero co-payment through the Section 100 Close the Gap PBS Co-payment Programme. Ensure all eligible patients are identified and the benefit is applied at dispensing.

📚 References

1. Machado GC, Maher CG, Ferreira PH, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ. 2015;350:h1225.
2. Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018;319(9):872–882.
3. Busse JW, Wang L, Kamaleldin M, et al. Opioids for chronic noncancer pain: a systematic review and meta-analysis. JAMA. 2018;320(23):2448–2460.
4. Derry S, Wiffen PJ, Kalso EA, et al. Topical analgesics for acute and chronic pain in adults — an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;5:CD008609.
5. Moore RA, Derry S, Aldington D, Cole P, Wiffen PJ. Amitriptyline for neuropathic pain in adults. Cochrane Database Syst Rev. 2015;(7):CD008242.
6. Lunn MPT, Hughes RAC, Wiffen PJ. Duloxetine for treating painful neuropathy, chronic pain or fibromyalgia. Cochrane Database Syst Rev. 2014;(1):CD007115.
7. Derry S, Bell RF, Straube S, Wiffen PJ, Aldington D, Moore RA. Pregabalin for neuropathic pain in adults. Cochrane Database Syst Rev. 2019;1:CD007076.
8. Royal Australian College of General Practitioners (RACGP). Prescribing drugs of dependence in general practice — Part C2: the role of opioids in pain management. Melbourne: RACGP; 2022.
9. Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists (FPM ANZCA). Statement regarding the use of opioid analgesics in patients with chronic non-cancer pain. Melbourne: ANZCA; 2023.
10. Australian Institute of Health and Welfare (AIHW). Chronic pain in Australia. Cat. no. PHE 267. Canberra: AIHW; 2020.
11. National Prescribing Service (NPS MedicineWise). Opioids, chronic non-cancer pain and the bigger picture. Surry Hills: NPS MedicineWise; 2021.
12. Centre for Behavioural Research in Cancer (CBRC) / Therapeutic Goods Administration (TGA). Codeine re-scheduling: implementation outcomes and prescribing impacts in Australia. Canberra: Department of Health; 2020.
13. Doran E. Off-label prescribing of opioids for chronic pain. Aust Prescr. 2020;43(4):122–125.
14. Australian and New Zealand College of Anaesthetists (ANZCA), Faculty of Pain Medicine. Recommendations regarding the use of opioid analgesics in patients with chronic non-cancer pain. Melbourne: ANZCA; 2023.
15. Schug SA, Palmer GM, Scott DA, Halliwell R, Trinca J. Acute pain management: scientific evidence (4th edition). Anaesthesia and Intensive Care. 2015;(Suppl):1–68.
16. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines. Br J Sports Med. 2020;54(2):79–86.
17. RhDAustralia (Remote Health Delivery Australia). Clinical guidelines for the management of pain in Aboriginal and Torres Strait Islander peoples. Darwin: Menzies School of Health Research; 2022.
18. Penm J, MacKinnon NJ, Strakosch E, Eggleton A. Opioid-related deaths and the role of drug interaction monitoring in Australia. Aust Health Rev. 2020;44(4):569–575.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).