When managing patients with chronic non-malignant pain, the aim is to maximise use of non-pharmacological treatments
and non-opioid analgesics, and to avoid using opioid analgesics where possible. Most patients can be managed in primary
care, but discussion with, or referral to, a specialist pain clinic may be required in some cases. This may include patients
with pain that is difficult to treat or when multiple treatment failures have occurred.
A treatment approach that incorporates both pharmacological (non-opioid) and non-pharmacological interventions
is recommended. This method has been found to be more effective in managing chronic pain than single treatment
modalities. This is supported by a 2008 systematic review, that included 35 randomised studies (2407 patients), which
investigated the use of multidisciplinary treatments* in patients with chronic musculoskeletal pain (mostly chronic back
pain or fibromyalgia). The review reported that there was “moderate” evidence of better effectiveness of multidisciplinary
treatments compared to single treatments in the treatment of this patient group.14
There are a wide range of social, psychological, non-pharmacological and non-opioid pharmacological treatment
options available for patients with chronic non-malignant pain. The best combination of treatments will vary
between patients depending on a number of factors. These include the underlying pain complaint, e.g. nociceptive versus
neuropathic pain, the mind-set and demographics of the patient, e.g. older and younger patients may have different expectations
and preferences for different treatments, the severity and duration of the pain, and the availability and affordability
of different treatment options. It may be necessary to trial different combinations of treatments in order to find the
best combination that suits the individual patient.
*Multidisciplinary treatments in the studies included cognitive behavioural therapy (CBT), psychotherapy,
exercise programmes (including stretching and hydrotherapy), patient education, muscle relaxation, nutritional counselling,
and vocational and occupational therapy.
Non-pharmacological treatment options for chronic pain
Physical activity is beneficial for people with pain as it can improve, or stop deterioration, in a number of parameters,
including range of motion and flexibility, and the pain associated with these. The choice of exercise programme will vary
depending on the patient’s pain condition and physical capabilities. A patient may choose a structured exercise programme,
or may prefer self-directed activities such as walking or swimming; these activities may be particularly beneficial in
patients with osteoarthritis of the lower limbs or chronic back pain. Patients who are initially reluctant to begin exercise
can be advised to gradually increase their level and duration of activity.
A Cochrane systematic review reported that exercise therapy was slightly effective in decreasing pain and improving
function in adults with chronic low-back pain, and at least as effective as other conservative treatments, e.g. behavioural
approaches.15 The positive effects of exercise programmes were most pronounced in patients who presented to healthcare
providers and received individually-designed programmes that commonly included strengthening or trunk-stabilising exercises.15
Pilates: A systematic review concluded that regular sessions of pilates (one to three times per week)
resulted in greater improvements in pain and function than usual care and physical activity in the first 4 – 15 weeks
in patients with chronic low-back pain.16
Yoga: A randomised trial that investigated the efficacy of the addition of yoga to usual care in patients
with chronic low-back pain found that pain and function were both improved (at three, six and 12 months) in patients who
underwent at least three yoga sessions.17
Tai Chi: A systematic review found that regular sessions of Tai Chi (on average one to two times per
week for 6 – 15 weeks) had small positive short-term effects on pain and disability in patients with chronic musculoskeletal
pain due to arthritis.18 However, the studies included were generally of low quality.
Brisk walking and home-based quadriceps strengthening exercises have both been reported to significantly reduce pain
and disability in patients with osteoarthritis of the knee.19 Weight reduction in overweight patients with osteoarthritis
of the knee has also been shown to improve pain and function scores.20
Massage therapy may have some benefits compared with placebo and relaxation in patients with chronic low-back pain in
the short term, according to the results of a systematic review.21 However, there were conflicting and contradictory findings
regarding the effectiveness of massage therapy when compared to other manual therapies (such as mobilisation) and acupuncture.21
The use of topical rubefacients during massage can also be recommended, e.g. heat rubs.
Acupuncture and nerve stimulation techniques
A systematic review and meta-analysis reported that acupuncture improved pain outcomes in patients with four chronic
pain conditions – back and neck pain, osteoarthritis, chronic headache and shoulder pain.22
Transcutaneous electrical nerve stimulation (TENS) is a form of nerve stimulation for pain relief and involves delivery
of low-voltage electrical current to the skin via surface electrodes. However, systematic reviews have found variable
and inconclusive results for TENS in patients with chronic pain.23
Cognitive behavioural therapy (CBT)
CBT (individual or group) is one of the more commonly used behavioural approaches for treating patients with chronic
pain. CBT focuses simultaneously on the environment, behaviour and cognition. The efficacy of CBT has been investigated
in a number of chronic pain conditions including fibromyalgia and low back pain. A randomised study conducted in patients
with chronic low-back pain in England reported that six sessions of group CBT resulted in significantly better pain and
disability scores (p <0.001 for both) compared with the control group (no CBT).24 Another study reported that CBT improved
the patient’s ability to cope with pain, reduced depressive moods and reduced the number of follow-up appointments in
patients with chronic pain due to fibromyalgia, but had no significant effects on the actual pain, fatigue, sleep and
quality of life.25
The access to, and cost of, CBT in New Zealand varies throughout the country and can be a significant barrier to treatment.
Some primary care clinicians may be trained in this technique, but referral to a Clinical Psychologist or Pain Specialist
may be required.* When access to specialist CBT is not possible, there are some internet-based programmes available which
have been shown to be effective in helping patients manage their pain (see below for details). A US-based study that examined
the effectiveness of an internet-based CBT chronic pain management programme (mostly in patients with joint, back and
osteoarthritic pain) reported positive results.26 The study found that pain intensity was significantly reduced from baseline
after both one and six months, and quality of life was also improved after six months.
An example of on online CBT programme that can be recommended for patients is
available at: www.getselfhelp.co.uk/chronicfp.htm
Other treatment options and useful advice that can be given to patients
Other non-pharmacological treatment options for chronic non-malignant pain that can be considered include:
- Hot or cold compresses, depending on the pain condition and specific benefit, e.g. hot packs can be beneficial in
patients with chronic back pain and cold packs can be beneficial in patients with pain due to osteoarthritis of the knee
- Biofeedback (the process of gaining greater awareness of many psychological functions, e.g. pain perception) and mind-body
activities such as meditation, mindfulness and relaxation can also be considered, mostly in combination with other treatments
- Encourage the patient to engage in activities they enjoy or that make them laugh
- Referral to an Occupation Therapist who can assist with postural problems, e.g. in a patient with a repetitive strain
injury due to work
- Referral to a Physiotherapist, Chiropractor or Osteopath who can perform massage, strapping, mobilisation and manipulation
*The Aotearoa New Zealand Association for Cognitive Behavioural Therapy (AnzaCBT) offer courses
and workshops on CBT, and more information is available at: www.cbt.org.nz
Cognitive behavioural therapy for pain
The principle behind CBT is in examining the relationship between a person’s thoughts, feelings and behaviours, and
understanding that these factors are dependent on each other.
The patient may begin with:
“If I move, I will hurt more” (thoughts)
“This makes me feel anxious about doing anything” (feelings)
“I will avoid doing anything that might hurt” (behaviour)
This then progresses to:
“No one cares about my pain, and no one can fix me” (thoughts)
“I feel angry that no one cares, and fearful that I cannot be fixed” (feelings)
“This makes me tense and irritable” (behaviour)
The purpose of CBT is to help patients avoid feeling overwhelmed by the pain they are experiencing, and instead come
to terms with their pain and feel that it is manageable. This means that the patient moves from a passive to an active
role in their care, focusing on increasing their function and quality of life.
The goals of the clinician are to:
- Actively listen to the patient’s experience of their pain
- Provide education about the cause of pain (if possible) and possible treatments
- Help patients find additional resources and support groups
- Set goals for the patient to achieve
- Solve problems that happen along the way
- Encourage engagement
- Positively reinforce any successes
For further information, see: Promoting mind-body approaches to pain self-management,
by Debra Hughes. Available from: www.empr.com
Pharmacological treatment options for chronic pain
Pharmacological treatment should not be the sole focus in managing patients with chronic non-malignant pain and should
be used in combination with non-pharmacological interventions. As with non-pharmacological treatments, the most appropriate
treatment (or combination of treatments) will vary between patients, and individual treatment trials should be undertaken.
When undertaking a trial, use the pre-intervention level of pain and function to assess whether the medicine(s) is working.
Analgesic treatment options for chronic non-malignant pain may include*:27
- NSAIDs: naproxen (up to 1000 mg per day) or ibuprofen (up to 1200 mg per day) are the recommended first-line choices
if NSAIDs are required for longer periods of time, due to the lower risk of cardiovascular events occurring when these
medicines are taken at these doses, compared to other NSAIDs.28 N.B. ibuprofen may be taken up to 2400 mg per day, but
this is associated with increased cardiovascular risk.
- Tricyclic antidepressants, e.g. amitriptyline, nortriptyline (less sedating)
- Other neuromodulators, e.g. gabapentin, carbamazepine
- Topical analgesics, e.g. NSAIDS, capsaicin
Referral to secondary care to investigate surgical options, permanent nerve blocks, epidural steroid injections and
spinal cord stimulation may be appropriate for some patients.
*A number of these medicines are not subsidised or approved for use in pain management in New
Zealand. For example, tricyclic antidepressants are not approved for neuropathic pain (but are frequently
used for this indication) and capsaicin is subject to subsidy restrictions. Pregabalin and duloxetine are sometimes used
for chronic non-malignant pain, but are not subsidised in New Zealand. Refer to the New Zealand Formulary for further
information on approved indications and subsidies.
Weaker/atypical opioid treatment options
Codeine, tramadol and dihydrocodeine can be considered as treatment options in combination with non-pharmacological
and non-opioid analgesics in patients with chronic non-malignant pain.
Codeine is a pro-drug which is metabolised to morphine by the liver enzyme CPY2D6 to achieve its analgesic effect. Genetic
differences mean that there is variation in how people metabolise codeine (either fast or slow metabolisers). Dihydrocodeine
is similar to codeine in both its structure and analgesic effect. Tramadol is classed as an “atypical” opioid as it is
both a relatively-weak mu opioid receptor agonist and a noradrenaline and serotonin reuptake inhibitor.29
Codeine, dihydrocodeine and tramadol are not recommended for use in patients with renal impairment. Use of all opioids
is associated with constipation, but this can be particularly problematic with codeine. Co-prescription of a laxative
is recommended. Tramadol may be more associated with nausea, vomiting, dizziness and sedation than codeine.
Strong opioids are ideally a “last resort”
When all other treatment options have failed, the clinician may decide that a strong opioid is the only treatment option
available when the patient has moderate to severe chronic non-malignant pain. When a strong opioid is indicated, morphine
is the first-line choice. Fentanyl patches are sometimes considered in patients with severe chronic pain. However, they
are best reserved for patients with constant and stable opioid requirements.