Chronic Pain: Causes, NHS Treatment & Self-Management

Chronic pain — defined as pain persisting for more than three months — affects around 28 million adults in the UK, making it one of the most prevalent health conditions in the country. Unlike acute pain, which is a direct signal of tissue damage, chronic pain often persists after healing or has no identifiable physical cause. This guide explains the types, causes, NHS treatment pathways (NICE NG193), and evidence-based self-management strategies.

What Is Chronic Pain?

Chronic pain is pain that persists beyond the normal healing time of an injury or illness, typically defined as lasting more than three months. NICE guideline NG193 (2021) divides chronic pain into two broad categories:

• Chronic primary pain: Pain is the primary condition, not explained by another diagnosis. Includes fibromyalgia, chronic widespread pain, chronic primary headache, chronic primary musculoskeletal pain, and chronic primary visceral pain. The pain itself is considered the disease.
• Chronic secondary pain: Pain occurs as a symptom of an underlying condition. Examples include chronic cancer-related pain, chronic post-surgical pain, chronic neuropathic pain (e.g., from diabetes or shingles), and chronic secondary musculoskeletal pain (e.g., from arthritis).

This distinction matters because it guides treatment. For chronic primary pain, NICE recommends against many treatments that would be appropriate for secondary pain — including long-term opioids, gabapentinoids (gabapentin, pregabalin), and routine investigations.

Causes and Contributing Factors

Chronic pain involves complex changes in the nervous system — a process known as central sensitisation, where the brain and spinal cord become hypersensitive to pain signals. Contributing factors include:

• Nervous system sensitisation: Pain pathways become “rewired,” amplifying signals even from non-painful stimuli
• Psychological factors: Anxiety, depression, and catastrophising (negative thought patterns about pain) are strongly associated with chronic pain severity and disability
• Sleep disruption: Poor sleep both causes and worsens chronic pain — a bidirectional relationship
• Social factors: Isolation, unemployment, and lack of social support predict worse outcomes
• Previous trauma: Adverse childhood experiences (ACEs) and PTSD are associated with higher rates of chronic pain
• Deconditioning: Fear of movement (kinesiophobia) leads to physical deconditioning, which worsens pain

NICE NG193 Recommendations (2021)

The 2021 NICE guideline on chronic primary pain represented a significant shift in NHS practice, moving away from passive and pharmacological treatments towards active, self-management-focused approaches:

Recommended Treatments

• Exercise therapy: The most strongly recommended intervention. Any supervised exercise programme — physical, psychological, or combination — is beneficial. This includes walking programmes, swimming, yoga, tai chi, physiotherapy, and graded exercise therapy.
• Acceptance and Commitment Therapy (ACT): A third-wave CBT approach that focuses on accepting pain rather than fighting it, and committing to values-based action. NICE specifically recommends ACT for chronic primary pain.
• Cognitive Behavioural Therapy (CBT): Helps address unhelpful thought patterns, catastrophising, and fear-avoidance beliefs.
• Antidepressants (duloxetine, amitriptyline): Low-dose antidepressants have modest evidence for chronic pain independent of their antidepressant effects, and may be offered alongside exercise and psychological therapy.
• Pain Management Programmes (PMPs): Multidisciplinary inpatient or outpatient programmes combining exercise, psychology, education, and self-management skills. NHS referral via GP or pain specialist.

Treatments NOT Recommended for Chronic Primary Pain (NICE NG193)

• Opioids (including codeine, tramadol, morphine, oxycodone, fentanyl) — not recommended; insufficient evidence of long-term benefit, significant risk of dependence and harm
• Gabapentinoids (gabapentin/pregabalin) — not recommended; no evidence of benefit in chronic primary pain; associated with abuse potential and accidental overdose
• Benzodiazepines — not recommended
• Ketamine — not recommended outside specialist settings
• Corticosteroid injections — not recommended for chronic primary pain
• Paracetamol and NSAIDs — limited long-term benefit for chronic primary pain

NHS Pain Management Pathways

Accessing NHS support for chronic pain typically involves:

• GP: First contact. May offer initial investigations, refer to physiotherapy, or prescribe low-dose antidepressants. Should also consider referral to secondary care if the cause is unclear or pain is severe.
• Physiotherapy: Direct referral from GP for exercise-based assessment and supervised exercise programmes.
• Community-based pain services: Some areas have GP-with-a-special-interest (GPwSI) pain clinics offering assessment and treatment without hospital referral.
• Hospital pain clinic: Specialist multidisciplinary assessment; may include nerve blocks, interventional procedures (for secondary pain), and access to Pain Management Programmes.
• Pain Management Programmes (PMPs): Typically 2–4 weeks as an outpatient, combining psychology (CBT/ACT), physiotherapy, and occupational therapy. Good evidence for improving function and quality of life, though not cure.

Self-Management Strategies

Self-management is central to living well with chronic pain. Evidence-based approaches include:

• Pacing: Breaking activity into manageable chunks with planned rest periods to prevent boom-bust cycles of overdoing followed by crashes
• Sleep hygiene: Consistent sleep times, cool dark room, limiting screen time before bed — addressing sleep can significantly reduce pain intensity
• Mindfulness-based stress reduction (MBSR): 8-week structured programme with good evidence for chronic pain
• Heat therapy: Warm baths, heated pads — modest short-term relief for musculoskeletal pain
• TENS machines: Transcutaneous electrical nerve stimulation; modest evidence, no serious side effects
• Social support: Pain support groups (in person and online) reduce isolation and improve coping — ask your pain clinic about local groups or visit Pain UK (painuk.org)

Chronic Pain and Mental Health

Chronic pain and mental health conditions are closely linked — around 50% of people with chronic pain also experience depression or anxiety. The relationship is bidirectional: pain causes psychological distress, and psychological distress amplifies pain perception. NICE recommends that mental health needs should be assessed and addressed as part of chronic pain management. NHS Talking Therapies (self-referral available) offers free CBT for people with chronic physical health conditions including pain.

Work, Benefits, and Chronic Pain

Chronic pain is a leading cause of work absence and disability in the UK. You may be entitled to:

• Personal Independence Payment (PIP): For those over 16 whose chronic pain limits daily living or mobility
• Employment and Support Allowance (ESA): For those unable to work due to chronic pain
• Fit Note (Med 3): GP can issue a fit note advising on work capability, including phased return or adjusted duties
• Access to Work: Government scheme funding workplace adaptations for people with health conditions