Arthritis Research UK's advice for patients with long-term pain starts with reference to the three-step approach at the core of the World Health Organization's 'analgesic ladder':15

1.     Start with simple analgesics such as paracetamol or NSAIDs.

2.     If this is not adequate, consider weak opioids such as codeine, dihydrocodeine and tramadol.

3.     If this is insufficient, consider strong opioids such as morphine, oxycodone, fentanyl and buprenorphine.

Pharmacotherapy can include other adjuvant drugs, such as antidepressants (amitriptyline and duloxetine) and anticonvulsants (eg gabapentin and pregabalin).

However, the Royal College of Anaesthetists' Faculty of Pain Medicine advises that taking such a stepped approach is not necessarily the right way to go in long-term pain. While it may be suitable for acute and end-of life pain, the Faculty says that medication for persistent pain should not be decided by how the patient reports pain intensity.16

Instead, it advises: €Medications are usually a small part of the pain management plan and should be used in conjunction with non-pharmacological interventions such as advice regarding activity, physiotherapy and an explanation that pain may be resistant to medication and complete relief of symptoms is not a goal of therapy.€

In addition: €Regardless of pain intensity, it is rational to start with non-opioid drugs, where these have some demonstrated efficacy for the condition being treated.€ Health professionals should also regularly review a patient's analgesia to ensure a drug is still effective, and to consider whether the dose could be adjusted or if that level of intervention is still required.

In the spring of 2017, the British Medical Association issued guidance promoting a safer analgesic prescribing policy. It also endorses non-pharmacological interventions, saying healthcare professionals €should be familiar with the range of non-pharmacological interventions that may be effective for the management of chronic pain €“ including physical and psychological therapies. Healthcare professionals should also be aware of the local availability of these services.€17