๐ Key Information Summary
- Chronic pain (persistent pain lasting โฅ3 months) is a complex sociopsychobiomedical condition affecting ~3.4 million Australians and is the leading cause of disability nationally.
- A biopsychosocial assessment โ not a purely biomedical one โ is the foundation of effective chronic pain management in primary care.
- Validated tools such as the Brief Pain Inventory (BPI), painDETECT, DN4, and patient-reported outcome measures (PROMs) should be used to characterise pain type, severity, and functional impact.
- Screen for yellow flags (psychosocial risk factors: catastrophising, fear-avoidance, depression, anxiety, work-related stress) at every assessment โ they are the strongest predictors of poor outcomes.
- Patient education that explains the neuroscience of pain (pain neuroscience education, PNE) reduces fear-avoidance and catastrophising and improves engagement with active rehabilitation.
- Self-management is the cornerstone of chronic pain care; clinicians should partner with patients to set SMART goals around function, not solely pain intensity.
- Non-pharmacological therapies (exercise, cognitive behavioural therapy, physiotherapy, mindfulness-based stress reduction) are first-line; pharmacotherapy is adjunctive.
- When medicines are trialled, start low and go slow; regular review with defined treatment goals and stop-rules reduces the risk of long-term polypharmacy and harm.
- Opioids have a limited role in chronic non-cancer pain; if trialled, use the lowest effective dose for the shortest duration with clear functional goals and an exit strategy.
- Monitor outcomes using validated tools (NRS/VAS, Patient Global Impression of Change, functional measures) at every visit; โฅ30% reduction in pain or meaningful functional improvement defines a positive response.
- Aboriginal and Torres Strait Islander Australians experience chronic pain at 1.4 times the rate of non-Indigenous Australians, with significant barriers to culturally safe, multimodal care.
- Multidisciplinary pain management programmes (MPPs) are evidence-based and MBS-rebated (Items 80100โ80125) but remain inaccessible to many rural and remote Australians; telehealth is an expanding option.
Introduction & Australian Epidemiology
Chronic pain โ defined by the International Association for the Study of Pain (IASP) as pain persisting or recurring for more than three months โ is one of the most common and disabling conditions encountered in Australian general practice. Unlike acute pain, which serves a protective biological warning function, chronic pain represents a maladaptive state in which the nervous system continues to signal threat in the absence of ongoing tissue damage or beyond the expected healing period.
Chronic pain is best understood through a sociopsychobiomedical framework. Biological factors (nociceptive, nociplastic, and neuropathic mechanisms), psychological factors (beliefs, mood, catastrophising, self-efficacy), and social determinants (employment, social isolation, socioeconomic disadvantage, cultural context) all interact to shape the pain experience and its functional consequences. This paradigm has replaced the outdated dualistic model that positioned pain as either "real" (organic) or "in the head" (psychogenic).
Key concept โ Nociplastic pain: Many chronic pain conditions (e.g., fibromyalgia, chronic widespread pain, irritable bowel syndrome) involve nociplastic pain โ altered nociception despite no clear evidence of tissue damage or somatosensory system lesion. Recognising this mechanism is critical because treatments targeting peripheral nociception alone (e.g., escalating opioids or repeated surgery) are ineffective and potentially harmful.
Australian Epidemiology
- Approximately 3.4 million Australians (16% of the population) live with chronic pain, projected to rise to 5.3 million by 2050 due to population ageing (Pain Australia, 2023; AIHW, 2023).
- Chronic pain is the leading cause of early retirement and disability burden in Australia, accounting for an estimated 9 billion annually in direct health costs, lost productivity, and carer costs (Painaustralia, 2019).
- Prevalence increases with age: ~28% of Australians aged โฅ65 report chronic pain (ABS National Health Survey, 2022).
- Women are disproportionately affected (prevalence ratio ~1.3:1), with specific conditions such as fibromyalgia, migraine, and pelvic pain contributing to this disparity.
- Aboriginal and Torres Strait Islander Australians experience chronic pain at 1.4 times the rate of non-Indigenous Australians, with onset at younger ages and greater functional impact (AIHW, 2023).
- Low back pain, neck pain, osteoarthritis-related pain, headache/migraine, and neuropathic pain are the most common chronic pain presentations in Australian primary care.
- Despite national guidelines recommending multimodal care, access to multidisciplinary pain services remains severely limited in rural and remote areas, with most specialist pain clinics concentrated in metropolitan centres.
Pain Classification (IASP, 2020)
| Mechanism | Definition | Examples |
|---|---|---|
| Nociceptive | Pain arising from actual or threatened damage to non-neural tissue, due to activation of nociceptors | Osteoarthritis, post-surgical, mechanical low back pain |
| Neuropathic | Pain caused by a lesion or disease of the somatosensory nervous system | Diabetic peripheral neuropathy, post-herpetic neuralgia, spinal cord injury pain |
| Nociplastic | Pain arising from altered nociception despite no clear evidence of tissue damage or somatosensory lesion | Fibromyalgia, chronic widespread pain, irritable bowel syndrome |
| Mixed | Combination of nociceptive, neuropathic, and/or nociplastic mechanisms | Chronic low back pain with radiculopathy, cancer pain |
Assessment
A thorough, structured assessment is the foundation of effective chronic pain management. The goal is not simply to "find the cause" through biomedical investigation, but to understand the whole-person experience of pain โ its mechanisms, its impact on function and wellbeing, and the psychosocial factors that perpetuate disability. The initial assessment typically requires more than one consultation.
Step 1: Comprehensive History
- Pain characterisation: Site, radiation, onset, duration, temporal pattern (constant vs intermittent), quality (burning, shooting โ neuropathic; aching, throbbing โ nociceptive), aggravating and relieving factors.
- Functional impact: Effect on work, sleep, mood, relationships, physical activity, and activities of daily living (ADLs). Use open-ended questions: "What can't you do now that you could do before?"
- Previous treatments: Medications (dose, duration, response, side effects), physical therapies, psychological interventions, interventional procedures, surgeries. Document what helped and what didn't.
- Comorbidities: Depression, anxiety, sleep disorders, substance use disorders, obesity, and other chronic conditions โ these commonly co-exist and must be managed concurrently.
- Medications review: Current analgesic use including over-the-counter agents, complementary medicines, and assess for medication overuse headache if applicable.
- Patient beliefs and expectations: What does the patient think is causing their pain? What do they expect from treatment? Understanding these beliefs is essential for education and shared decision-making.
Step 2: Targeted Physical Examination
- Focused musculoskeletal and neurological examination appropriate to the pain presentation.
- Assess for signs of neuropathic pain: allodynia, hyperalgesia, sensory deficits, allodynia in a dermatomal pattern.
- Identify red flags that warrant urgent investigation (see below).
- Observe posture, movement patterns, pain behaviours, and functional capacity.
Step 3: Screen for Red Flags
Red flags requiring urgent investigation/referral: Unexplained weight loss, history of malignancy, fever/chills/night sweats, bowel or bladder dysfunction, saddle anaesthesia, progressive neurological deficit, recent significant trauma (especially in the elderly or those on anticoagulants), pain that is progressive and unremitting despite treatment, and signs of cauda equina syndrome. These require same-day imaging and specialist assessment.
Step 4: Screen for Yellow Flags (Psychosocial Risk Factors)
Yellow flags are the strongest predictors of progression from acute to chronic pain and of poor functional outcomes. They should be screened at every assessment:
| Yellow Flag Domain | Indicators |
|---|---|
| Beliefs & attitudes | "My pain will never get better," "I need a scan to find the problem," belief that pain = damage/harm |
| Fear-avoidance | Avoidance of activity due to fear of re-injury or worsening pain; excessive rest |
| Catastrophising | Rumination, magnification, helplessness about pain ("This is the worst pain imaginable and nothing helps") |
| Mood | Depression, anxiety, irritability, emotional lability; PHQ-9 โฅ10 and GAD-7 โฅ10 warrant concurrent treatment |
| Work / compensation | Work-related injury, dissatisfaction at work, active workers' compensation claim, workplace conflict |
| Social | Social isolation, relationship stress, low socioeconomic status, history of adverse childhood experiences |
Validated Assessment Tools
Essential
Numeric Rating Scale (NRS) or Visual Analogue Scale (VAS)
0โ10 pain intensity; record at every visit. A โฅ30% reduction (e.g., 7โ5) is considered a clinically meaningful improvement.
Essential
Brief Pain Inventory (BPI) โ Short Form
Assesses pain severity and pain interference with function (general activity, mood, walking, work, relations, sleep, enjoyment). Freely available; validated Australian English version.
Available
painDETECT Questionnaire (PD-Q)
Self-report screening for neuropathic pain components; score โฅ19 suggests predominantly neuropathic pain. Useful to guide analgesic selection.
Available
DN4 (Douleur Neuropathique 4)
Clinician-administered neuropathic pain screening tool; โฅ4/10 suggests neuropathic pain. Includes clinical examination items (brush allodynia, pinprick hypalgesia).
Available
Central Sensitisation Inventory (CSI)
25-item questionnaire assessing symptoms associated with central sensitisation; score โฅ40 suggests clinically relevant central sensitisation. Useful for identifying nociplastic pain mechanisms.
Available
รrebro Musculoskeletal Pain Screening Questionnaire
Predicts risk of long-term disability and work loss; score โฅ105 indicates high risk. Recommended in the Australian acute low back pain guidelines but applicable to chronic presentations.
Available
PHQ-9 (depression) and GAD-7 (anxiety)
Screen for comorbid mood disorders; treat concurrently. PHQ-9 โฅ10 = moderate depression; GAD-7 โฅ10 = moderate anxiety.
Available
Patient Global Impression of Change (PGIC)
7-point scale from "very much improved" to "very much worse"; patient-reported anchor for treatment response. Recommended as a core outcome measure.
Investigations
Investigations in chronic pain should be guided by clinical findings, not performed reflexively. The presence of chronic pain alone does not justify routine imaging. Unnecessary investigations can reinforce the belief that there is an undiagnosed structural cause and contribute to the "diagnostic cascade" of incidental findings.
Avoid routine imaging for non-specific chronic low back pain: NICE (2020) and Australian Commission on Safety and Quality in Health Care (ACSQHC) guidelines recommend against routine lumbar spine MRI or X-ray in the absence of red flags. Imaging findings (disc degeneration, disc bulges, facet arthropathy) are highly prevalent in asymptomatic populations and correlate poorly with symptoms.
Essential
Full blood examination (FBE)
Screen for anaemia, inflammatory markers if systemic illness suspected. MBS Item 65070.
Essential
ESR / CRP
If inflammatory arthropathy, infection, or malignancy suspected. MBS Item 65070/66556.
Available
HbA1c, fasting glucose
If diabetic neuropathy suspected; MBS Item 66841.
Available
Vitamin D (25-OH)
Widespread musculoskeletal pain may be associated with deficiency; common in Australian elderly and ATSI populations. MBS Item 66820.
Referral
MRI (region-specific)
Only with red flags, progressive neurological deficit, or failure to respond to 6 weeks of conservative management. MBS Item 63001โ63563.
Specialist
Nerve conduction studies / EMG
Suspected peripheral neuropathy, radiculopathy, or entrapment neuropathy. MBS Item 11000โ11005. Refer to neurologist or rehabilitation specialist.
Shared Decision-Making and Goal Setting
After the assessment, the clinician should synthesise findings and discuss them with the patient using clear, non-jargon language. Goals should be SMART (Specific, Measurable, Achievable, Relevant, Time-bound) and focused on function, not solely pain intensity:
- "Walk to the shops (500 m) three times a week within 8 weeks"
- "Return to 4 hours of part-time work per day within 3 months"
- "Sleep through the night without waking from pain at least 5 nights per week"
Patients should leave the initial assessment understanding that chronic pain is real, that it involves changes in the nervous system, and that effective management requires an active, multidimensional approach โ not a single "fix."
Education
Patient education is a critical early intervention in chronic pain management. Effective education does not simply deliver information โ it changes the way patients understand and relate to their pain. Pain neuroscience education (PNE), also known as therapeutic neuroscience education, is the best-evidenced educational approach for chronic pain.
Pain Neuroscience Education (PNE)
PNE teaches patients about the neuroscience of pain, emphasising that:
- Pain is an output of the brain, not a direct readout of tissue damage. The brain decides whether to produce a pain experience based on multiple inputs (nociceptive, emotional, cognitive, contextual).
- The nervous system can become sensitised โ the "volume knob" on pain processing can be turned up centrally, so that normal inputs are perceived as painful (allodynia, hyperalgesia). This is not imaginary; it is a measurable neurological phenomenon.
- Pain does not equal damage in chronic pain. Hurt โ harm. Understanding this is critical to reducing fear-avoidance and re-engaging with activity.
- The nervous system is plastic and can change โ chronic pain is not permanent or irreversible. Graduated exposure, exercise, and cognitive strategies can "turn down the volume."
Evidence for PNE: Systematic reviews (Louw et al., 2011; Watson et al., 2019) demonstrate that PNE reduces pain catastrophising, pain-related fear, and pain intensity while improving function and physical performance. PNE is most effective when combined with active rehabilitation (exercise, graded activity).
Key Educational Messages
1
Validate the pain
"Your pain is real. Chronic pain involves real changes in how your nervous system processes signals. It is not 'in your head' and it is not imaginary."
2
Explain the sensitisation model
Use analogies: "Like a car alarm that goes off when a leaf falls on it โ the alarm system itself has become oversensitive, even though there is no real break-in."
3
Reframe beliefs about activity
"Movement is medicine, not a threat. Starting small and building up gradually will not damage you โ it retrains the nervous system."
4
Demystify investigations
"Many findings on scans (disc bulges, arthritis) are normal age-related changes, like grey hair on the inside. They do not explain your pain and are found in people with no pain at all."
5
Set realistic expectations
"The goal is not necessarily zero pain. The goal is for you to live a full, meaningful life and to have strategies to manage flare-ups when they occur."
Education Delivery Methods
- One-on-one consultations: Tailored to the individual; ideal for exploring beliefs and correcting misconceptions. GP chronic pain management plans (MBS Item 721) and follow-up reviews (MBS Item 723) provide funded time for this.
- Group education programmes: Delivered by multidisciplinary teams in hospital outpatient or community settings. Evidence supports group PNE for reducing catastrophising and improving self-efficacy.
- Written and online resources: Pain Australia (painaustralia.org.au), Explain Pain (Butler & Mosley), and the Hunter Integrated Pain Service patient resources are freely available, evidence-based Australian materials.
- Telehealth: Increasingly used post-COVID; suitable for rural and remote patients. MBS telehealth items (91790, 91800) provide equivalent rebates for video consultations.
Addressing Common Misconceptions
| Misconception | Evidence-Based Reframe |
|---|---|
| "I need a scan to find out what's wrong" | Imaging rarely changes management in non-specific chronic pain and may increase anxiety. Most findings are age-related and present in pain-free people. |
| "If it hurts, I'm causing damage" | Hurt โ harm in chronic pain. The nervous system has become sensitised. Gradual activity increase is safe and therapeutic. |
| "I should rest until the pain goes away" | Prolonged rest increases deconditioning, stiffness, and disability. Graded return to activity is evidence-based treatment. |
| "Only strong painkillers can help" | Medications are one part of a multimodal approach. Non-pharmacological strategies (exercise, sleep, psychological techniques) are equally or more effective long-term. |
| "Nothing can be done โ I just have to live with it" | While a "cure" may not exist, meaningful improvement in function, quality of life, and pain management is achievable for most people with chronic pain. |
Self-Management
Self-management is the cornerstone of chronic pain care. It refers to the individual's ability to manage symptoms, treatment, physical and psychosocial consequences, and lifestyle changes inherent in living with a chronic condition. The clinician's role shifts from "fixer" to "coach" โ supporting the patient to develop skills, confidence, and agency.
Clinician mindset shift: In acute pain, the clinician is the expert who diagnoses and treats. In chronic pain, the patient is the expert on their own experience; the clinician provides evidence-based guidance, education, and support for the patient to develop their own management toolkit.
Core Self-Management Strategies
1. Physical Activity & Exercise
Exercise is the single most evidence-based intervention for chronic pain. Benefits include reduced pain intensity, improved function, improved mood, better sleep, and reduced central sensitisation. The type of exercise matters less than consistency and gradual progression.
- Aerobic exercise: Walking, swimming, cycling โ aim for 150 minutes/week of moderate intensity. Start at a level the patient can manage (even 5 minutes) and increase by no more than 10โ20% per week.
- Strength/resistance training: 2โ3 sessions/week targeting major muscle groups. Particularly beneficial for osteoarthritis and chronic low back pain.
- Mind-body exercise: Yoga, tai chi, Pilates โ combine physical movement with mindfulness and breathing. Growing evidence base for chronic low back pain and fibromyalgia.
- Graded activity/exposure: Systematic, gradual increase in activity levels with explicit instruction that initial increases in pain are expected and safe. Break the pain-avoidance-deconditioning cycle.
Exercise flare management: Patients should be counselled that temporary increases in pain during or after exercise are normal and do not indicate tissue damage. Strategies include: reduce intensity by 50% for 2โ3 days, use heat/ice, gentle stretching, and relaxation techniques. Do not stop exercising entirely โ return to the previous tolerated level and build up again.
2. Cognitive & Psychological Strategies
- Pacing: Breaking activities into manageable segments with planned rest periods to avoid the "boom-bust" cycle (overdoing it on good days โ crash on bad days). A structured activity diary supports pacing.
- Relaxation techniques: Progressive muscle relaxation (PMR), diaphragmatic breathing, guided imagery. Evidence supports daily practice for reducing pain-related muscle tension and autonomic arousal.
- Mindfulness-based stress reduction (MBSR): 8-week structured programme; evidence supports improvements in pain acceptance, reduced catastrophising, and improved quality of life. Available through some Australian pain services and community programmes.
- Cognitive restructuring: Identifying and challenging unhelpful pain-related thoughts ("I'll never get better," "I need to be pain-free before I can do anything") and replacing them with more balanced, functional thinking.
- Acceptance and Commitment Therapy (ACT): Focuses on accepting pain as part of life while committing to actions aligned with personal values. Growing evidence base for chronic pain; delivered by psychologists (MBS Items 80000โ80015).
3. Sleep Hygiene
Sleep disturbance affects 50โ90% of people with chronic pain, and poor sleep amplifies pain sensitivity in a bidirectional relationship. Addressing sleep is a high-yield intervention:
- Consistent wake time (7 days/week), even after a poor night's sleep.
- Bedroom environment: cool, dark, quiet; bed for sleep and intimacy only.
- Avoid caffeine after midday; limit alcohol (disrupts sleep architecture).
- Wind-down routine 60 minutes before bed; reduce screen exposure.
- Cognitive Behavioural Therapy for Insomnia (CBT-I) is first-line for chronic insomnia and is available via psychologists, online programmes (e.g., Sleepio, This Way Up), and some pain services.
4. Flare-Up Management Plan
Every patient with chronic pain should have a written flare-up plan developed collaboratively with their GP. This normalises flare-ups as an expected part of chronic pain (not a sign of failure or new damage) and provides a structured response:
1
Acknowledge & accept
"This is a flare-up. It will pass. It does not mean my condition is getting worse."
2
Reduce (don't stop) activity
Drop to 50% of usual activity levels. Avoid bed rest. Gentle movement (short walks, stretches) is preferred.
3
Use toolkit strategies
Heat/cold packs, relaxation breathing, TENS (if previously helpful), distraction, and short-term medication adjustment if agreed in advance with the GP.
4
Gradually resume
After 2โ3 days, begin to return to the previous activity level. Use the same 10โ20% progression rule.
5
Review & learn
At the next GP visit, discuss the flare-up: what triggered it, what helped, and what to adjust in the plan.
5. Accessible Self-Management Resources (Australia)
| Resource | Type | Access |
|---|---|---|
| Pain Australia | National peak body; education, advocacy, resources | painaustralia.org.au |
| Pain Link | Peer support telephone service | 1300 340 357 |
| This Way Up โ Chronic Pain Course | Clinician-supervised online CBT programme | thiswayup.org.au (free with GP referral) |
| Hunter Integrated Pain Service (HIPS) | Patient resources, booklets, videos | hnehealth.nsw.gov.au/hips |
| Explain Pain (Butler & Mosley) | Book โ foundational PNE resource | Bookshops / NOI Group (noigroup.com) |
| My Health for Life | Free healthy lifestyle programme (Qld, expanding nationally) | myhealthforlife.com.au |
Multidisciplinary Pain Management Programmes (MPPs)
For patients with moderate-to-severe chronic pain and significant functional impairment despite primary care management, referral to a multidisciplinary pain programme is recommended. These programmes typically include:
- Pain medicine physician assessment
- Physiotherapy (graded exercise, manual therapy, pain neuroscience education)
- Psychology (CBT, ACT, mindfulness)
- Occupational therapy (functional rehabilitation, pacing, return-to-work support)
- Pharmacy review (rationalisation of analgesic polypharmacy)
- Nursing (care coordination, education)
MBS items for multidisciplinary care: GP Chronic Condition Management Plan (CCMP, Item 721) and review (Item 723) โ up to 5 allied health services per calendar year (Item 10950โ10970). Team Care Arrangements allow referral to physiotherapists, psychologists, exercise physiologists, and other allied health practitioners. Additional allied health sessions may be available for Aboriginal and Torres Strait Islander patients (up to 15 services under the Indigenous Chronic Disease Package).
Monitoring Outcomes
Regular, structured outcome monitoring is essential in chronic pain management. It provides objective data to guide treatment decisions, demonstrates progress (or lack thereof) to the patient and the care team, and prevents the inertia of "unchanged medications with no review." Monitoring should occur at every clinical encounter using validated tools.
Core Outcome Domains
The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommends measuring the following core outcome domains in chronic pain clinical trials and practice:
Domain 1
Pain Intensity
NRS 0โ10 or VAS at every visit. Clinically meaningful difference: โฅ30% reduction (e.g., 7โ5) or โฅ2-point change on NRS.
Tool: Numeric Rating Scale (NRS)
Domain 2
Physical Function
Ability to perform daily activities, work, and exercise. Interference subscale of the BPI; Oswestry Disability Index for back pain; WOMAC for osteoarthritis.
Tool: BPI Interference, ODI, WOMAC
Domain 3
Emotional Functioning
Depression (PHQ-9), anxiety (GAD-7), pain catastrophising (PCS). Treat concurrently โ mood and pain amplify each other.
Tool: PHQ-9, GAD-7, PCS
Domain 4
Patient Global Impression of Change
"Compared to before treatment, my overall condition isโฆ" (very much improved โ very much worse). The most patient-centred anchor for treatment response.
Tool: PGIC (7-point scale)
Domain 5
Sleep
Pittsburgh Sleep Quality Index (PSQI) or simple NRS for sleep quality. Bidirectional relationship with pain makes sleep a high-yield target.
Tool: PSQI, sleep NRS
Domain 6
Adverse Events & Medication Safety
Document side effects at every review. Monitor for opioid-specific risks (naloxone provision, dose escalation, aberrant behaviours).
Tool: Structured side-effect checklist
Defining Treatment Response
| Response Category | Criteria | Action |
|---|---|---|
| Positive response | โฅ30% pain reduction AND meaningful functional improvement (PGIC "improved" or "much improved") | Continue current plan; review at scheduled intervals (every 1โ3 months) |
| Partial response | Some improvement but goals not met | Optimise dose/delivery, add or change modality, intensify self-management support |
| No response | <30% pain reduction and no functional improvement after an adequate trial (typically 4โ8 weeks at therapeutic dose) | Deprescribe; switch to alternative approach; consider specialist referral |
| Deterioration | Worsening pain, function, or mood; new red flags; medication-related harm | Urgent review; re-assess for missed diagnosis; consider specialist referral |
Medication Review & Deprescribing
All analgesic medications should be reviewed at regular intervals with a focus on efficacy, side effects, and ongoing need. The principle of "start low, go slow, review often, and have an exit strategy" applies to all analgesics, especially opioids and gabapentinoids.
- Establish a review schedule: Every 2โ4 weeks during titration; every 1โ3 months once stable; every 6โ12 months for long-term established therapy.
- Set stop-rules at initiation: Agree with the patient in advance: "If we don't see meaningful functional improvement by [date/dose], we will taper and try something else."
- Deprescribing is not failure: Tapering an ineffective medication is a positive therapeutic action, not an admission of defeat. Frame this positively to patients.
- Opioid monitoring: For patients on long-term opioids, monitor using the Opioid Manager tool, conduct urine drug screening where clinically indicated, and check the real-time prescription monitoring system (SafeScript in Victoria, RAPID in SA, ScriptCheck in NT/Qld/NSW, DORA in WA, ACTMed in ACT, TasScript in Tasmania).
Real-time prescription monitoring (RTPM): All Australian states and territories now operate real-time prescription monitoring systems for high-risk medicines (opioids, benzodiazepines). Clinicians must check the relevant system before prescribing or dispensing Schedule 8 medicines. Failure to check may expose patients to harm and clinicians to medicolegal risk.
Monitoring Timeline Example
Week 0
Initial comprehensive assessment. Set SMART goals. Commence education (PNE). Baseline NRS, BPI, PHQ-9, GAD-7. Document treatment plan.
Week 2โ4
First follow-up: review response to education, assess engagement with exercise/self-management, medication titration review. Repeat NRS. Check for side effects.
Week 6โ8
Formal treatment response assessment. Repeat BPI, PGIC. If no response โ deprescribe/change approach. If partial โ optimise.
Month 3
Comprehensive review. Repeat PHQ-9, GAD-7 if previously elevated. Update flare-up plan. Consider referral to MPP if not progressing. Review allied health access under CCMP.
Month 6+
Ongoing maintenance reviews every 3โ6 months. Focus on self-management sustainability, goal re-assessment, and long-term medication safety. Annual comprehensive review.
Special Populations
Pregnancy
Paracetamol
First-line analgesic in pregnancy at standard doses (500 mgโ1 g QDS PRN). Considered safe across all trimesters. Avoid prolonged use where possible (recent epidemiological concern re: neurodevelopmental outcomes, though causality unconfirmed).
NSAIDs
Avoid in third trimester (risk of premature closure of ductus arteriosus, oligohydramnios). Short courses in first/second trimester only if benefit outweighs risk. Avoid ibuprofen, naproxen, diclofenac from 28 weeks.
Opioids
Avoid if possible. Associated with neonatal abstinence syndrome (NAS) with prolonged use. Short courses of low-dose codeine or oxycodone may be used under specialist guidance if non-opioid options insufficient.
Gabapentinoids (pregabalin, gabapentin)
Limited safety data; generally avoided. Use only under specialist supervision if benefit clearly outweighs risk.
Non-pharmacological approaches
Exercise (walking, swimming, prenatal yoga), physiotherapy, mindfulness, and TENS are preferred first-line strategies and are safe in pregnancy.
Paediatrics
General approach
Chronic pain in children and adolescents is common (prevalence ~25%) and often presents as headache, abdominal pain, or musculoskeletal pain. The biopsychosocial model applies. Family-centred care is essential โ parental beliefs and responses to pain strongly influence the child's experience.
Paracetamol
15 mg/kg PO QDS (max 60 mg/kg/day, max 4 g/day). Safe and appropriate first-line.
Ibuprofen
5โ10 mg/kg PO TDS (max 30 mg/kg/day or 2.4 g/day for children >30 kg). Short courses only.
Non-pharmacological
Cognitive behavioural therapy (CBT) and relaxation training have the strongest evidence in paediatric chronic pain. Graded exercise, school re-engagement, and family-based approaches are key. Referral to a paediatric pain service is recommended for moderate-severe cases.
Amitriptyline
Used off-label for chronic neuropathic pain in paediatrics; start 0.1โ0.25 mg/kg at night, titrate slowly. Requires ECG monitoring if dose escalation. Not PBS-listed for chronic pain in children (authority required for โฅ12 years).
Elderly (โฅ65 years)
General principles
Polypharmacy is a major concern; deprescribing should be actively pursued. Falls risk increases with opioids, gabapentinoids, and TCAs. Hepatic and renal function decline with age โ dose adjustment is essential. Pain may present atypically (e.g., confusion, withdrawal, reduced mobility rather than verbal report of pain).
Paracetamol
First-line. Max dose should generally be reduced to 2โ3 g/day in frail elderly or those with hepatic impairment. PBS General Benefit.
Topical NSAIDs
Preferred over systemic NSAIDs for localised musculoskeletal pain (e.g., diclofenac gel โ Voltaren Emulgelยฎ). Minimises systemic absorption and GI/renal/CV risk. PBS Restricted Benefit for osteoarthritis.
Opioids
Use with extreme caution. Increased risk of falls, cognitive impairment, constipation, respiratory depression. If required, start at 50% of the standard adult dose. Avoid tramadol if seizure risk. Review regularly with stop-rules.
Exercise
Tailored exercise programmes (strength, balance, flexibility) reduce pain AND falls risk. Referral to exercise physiologist or physiotherapist under CCMP. Group programmes (e.g., tai chi, hydrotherapy) combine social engagement with physical activity.
Renal Impairment
Paracetamol
Safe at standard doses in mild-moderate CKD. No dose adjustment required. First-line choice.
NSAIDs
Avoid in CKD stage 3b+ (eGFR <45 mL/min/1.73mยฒ). Risk of acute kidney injury, fluid retention, hyperkalaemia. Contraindicated in dialysis patients.
Gabapentin
Dose reduction required: 200โ300 mg after each dialysis session for patients on haemodialysis. Significant accumulation in renal impairment.
Pregabalin
Dose adjustment required based on eGFR. 25โ75 mg BD for eGFR 15โ30; 25โ50 mg daily for eGFR <15. Dose after dialysis.
Tramadol
Reduce dose and extend interval: max 200 mg/day in eGFR <30; avoid metabolite accumulation. Active metabolite removed by haemodialysis.
Immunocompromised
General principles
Chronic pain in immunocompromised patients (HIV, transplant recipients, chemotherapy, biologics) may be related to the disease itself, its treatment, or opportunistic infections. Differential diagnosis must include infection, malignancy progression, and drug-induced pain. NSAIDs should be used cautiously due to platelet and renal effects. Neuropathic pain is common (e.g., antiretroviral neuropathy, chemotherapy-induced peripheral neuropathy).
Amitriptyline
Useful for neuropathic pain; start 10 mg nocte, titrate by 10 mg every 1โ2 weeks. Monitor for anticholinergic effects, sedation. May cause neutropenia (rare) โ consider FBE monitoring.
Duloxetine
Effective for chemotherapy-induced peripheral neuropathy (CIPN). Start 30 mg daily for 1 week then 60 mg daily. PBS Authority Required for neuropathic pain.
Hepatic Impairment
Paracetamol
Reduce maximum dose to 2 g/day in significant hepatic impairment (Child-Pugh B or C). Hepatotoxicity risk increases with chronic liver disease, alcohol use, and malnutrition.
NSAIDs
Avoid in severe hepatic impairment. Risk of GI bleeding, fluid retention, hepatotoxicity. Contraindicated in portal hypertension.
Duloxetine
Contraindicated in severe hepatic impairment (Child-Pugh C). Use with caution in moderate impairment.
Amitriptyline
Use lower starting doses; hepatic metabolism is reduced. Monitor for excessive sedation and anticholinergic effects.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
Aboriginal and Torres Strait Islander Australians experience chronic pain at significantly higher rates than non-Indigenous Australians, with earlier onset, greater severity, more widespread pain presentations, and higher rates of comorbid mental health conditions and disability. Despite this burden, access to culturally safe, multimodal chronic pain care is profoundly inequitable.
Key Disparities
- Chronic pain prevalence is ~1.4 times higher in Aboriginal and Torres Strait Islander peoples compared to non-Indigenous Australians (AIHW, 2023).
- Musculoskeletal conditions (including chronic pain) are the leading cause of burden of disease in Aboriginal and Torres Strait Islander peoples (AIHW, 2022).
- Opioid dispensing rates are significantly higher in remote and very remote Indigenous communities compared to urban areas, with higher rates of opioid-related harm.
- Access to specialist pain services, psychologists, physiotherapists, and exercise physiologists is severely limited in rural and remote communities where many Aboriginal and Torres Strait Islander peoples live.
- Cultural determinants of health โ connection to Country, culture, community, and family โ are protective factors that are often disrupted by colonisation, dispossession, and intergenerational trauma, contributing to the chronic pain burden.
Culturally Responsive Approaches
- Use Aboriginal and Torres Strait Islander health workers and practitioners: They provide culturally safe care, health literacy support, and liaison between patients and the clinical team. The Aboriginal and Torres Strait Islander health worker role is funded through Aboriginal Community Controlled Health Organisations (ACCHOs) and state/territory health services.
- Yarning-based assessment: Adopt a relational, narrative approach to assessment rather than a rigid structured interview. "Dadirri" (deep listening) is a culturally grounded communication approach used in many Aboriginal health services.
- Holistic, whole-person models of care: Aboriginal and Torres Strait Islander models of health encompass physical, social, emotional, cultural, and spiritual wellbeing. Pain management should be integrated within this framework, not isolated as a purely biomedical problem.
- Connection to Country and culture: Support access to cultural activities, ceremony, and connection to Country as part of a holistic pain management plan. Cultural healing programmes (e.g., on-Country camps, traditional practices) are increasingly recognised as complementary approaches.
- ACCHOs as the preferred point of care: Where possible, chronic pain management should be delivered through or in partnership with Aboriginal Community Controlled Health Organisations, which provide culturally safe, holistic primary healthcare. There are over 140 ACCHOs nationally (NACCHO).
- Additional allied health sessions: Under the Indigenous Chronic Disease Package, Aboriginal and Torres Strait Islander patients can access up to 15 allied health services per year (compared to 5 for non-Indigenous patients under standard Medicare arrangements), enabling more intensive multimodal care.
- Close the Gap PBS co-payment: Aboriginal and Torres Strait Islander patients with, or at risk of, chronic disease can access PBS medicines at the concessional co-payment rate (.70 per script in 2024) through their ACCHO or mainstream GP. This significantly reduces medication cost barriers.
- Telehealth and digital health: Video consultations (MBS telehealth items) and digital pain management programmes can partially bridge the geographic gap, but digital literacy, internet connectivity, and privacy in crowded households remain challenges that must be addressed.
Opioid harm in remote Aboriginal communities: Opioid-related hospitalisations and deaths are disproportionately high in remote Aboriginal and Torres Strait Islander communities. GPs managing chronic pain in these settings must be particularly vigilant about opioid safety: prescribe at the lowest effective dose, use real-time prescription monitoring, co-prescribe naloxone (PBS-listed for opioid overdose reversal), and prioritise non-pharmacological approaches.
๐ References
- 1. Australian Institute of Health and Welfare (AIHW). Chronic pain in Australia. Cat. no. PHE 329. Canberra: AIHW; 2023.
- 2. Painaustralia. The cost of pain in Australia. Deakin, ACT: Painaustralia; 2019.
- 3. Nicholas MK, Blyth FM. Are self-management strategies effective in chronic pain treatment? Pain Management. 2013;3(1):75โ88.
- 4. RACGP. Prescribing drugs of dependence in general practice: Part B โ Opioids. Melbourne: The Royal Australian College of General Practitioners; 2022.
- 5. 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. British Journal of Sports Medicine. 2020;54(2):79โ86.
- 6. Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Physical Therapy. 2011;91(12):1708โ1720.
- 7. Turk DC, Dworkin RH, Allen RR, et al. Core outcome domains for chronic pain clinical trials: IMMPACT recommendations. Pain. 2003;106(3):337โ345.
- 8. Geneen LJ, Moore RA, Clarke C, et al. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews. 2017;(4):CD011279.
- 9. National Institute for Health and Care Excellence (NICE). Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE guideline NG193. London: NICE; 2021.
- 10. Australian Commission on Safety and Quality in Health Care (ACSQHC). Opioid analgesic stewardship in acute pain clinical care standard. Sydney: ACSQHC; 2022.
- 11. Department of Health and Aged Care (Cth). MBS Online โ Medicare Benefits Schedule. Canberra: Australian Government; 2024. Available at: mbsonline.gov.au.
- 12. National Aboriginal Community Controlled Health Organisation (NACCHO). National Aboriginal and Torres Strait Islander health plan 2021โ2031. Canberra: Commonwealth of Australia; 2021.
- 13. Jolliffe L, Moseley GL, Kamper SJ. The lived experience of chronic pain for Aboriginal and Torres Strait Islander Australians: a systematic review and thematic synthesis. BMC Public Health. 2022;22(1):1283.
- 14. Darnall BD, Sturgeon JA, Cook KF, et al. Development and validation of a daily pain catastrophising scale. The Journal of Pain. 2017;18(9):1139โ1152.
- 15. International Association for the Study of Pain (IASP). IASP announces revised definition of pain. Washington, DC: IASP; 2020.