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Pain Management (PI)

  • Pain is another common reason patients consult in general practice(1), encompassing a wide range of acute, chronic, and complex presentations. It can arise from identifiable pathology or exist without a clear underlying cause, and it affects individuals physically, psychologically, and socially. The GP’s role in assessing and managing pain is both frequent and multifaceted, requiring not only sound clinical knowledge, but also strong communication, empathy, and an understanding of the broader impact pain has on daily life.
     
    Effective pain management involves a combination of accurate diagnosis, patient education, and a tailored approach that may include pharmacological, physical, and psychological strategies. GPs must also be skilled in identifying red flags, avoiding over-reliance on medication (particularly opioids) and recognising when to involve multidisciplinary teams. Chronic pain, in particular, presents unique challenges, often requiring a biopsychosocial approach and a focus on supporting function and quality of life rather than complete symptom resolution. 

    This chapter aims to guide GP trainees towards the tools to assess, diagnose, and manage pain in a way that is safe, evidence-based, and person-centred, while recognising the complexity and individuality of each patient’s experience. 

    • PI1. Consider the different approaches necessary for acute pain and chronic pain.
    • PI2. Demonstrate the ability to assess and manage chronic pain effectively, including recognition of red and yellow flags, and providing patient education on pain management.
    • PI3. Consider the biopsychosocial and cultural factors that influence pain perception and treatment outcomes, ensuring a comprehensive and individualised approach.
    • PI4. Differentiate between tolerance, dependence, and addiction in the context of pain management, recognising their implications for treatment and patient care.
    • PI5. Formulate an understanding of both pharmacological and non-pharmacological interventions for pain, adopting a patient-centred, holistic approach to management.
    • PI6. Evaluate the effectiveness of opioid therapy for chronic pain, identifying appropriate cases for discontinuation and implementing safe tapering strategies when needed.
    • PI7. Acknowledge personal biases and judgements that may impact pain assessment and treatment decisions, developing strategies to ensure equitable and appropriate care.
    • PI8. Advocate for patients’ needs, ensuring access to appropriate pain management services and multidisciplinary support.
    • PI9. Employ effective teamwork, delegation, and resource management in pain management, collaborating with other healthcare professionals to optimise patient outcomes.

    For each problem or disease, consider the following areas within the general context of primary care:  

    • The natural history of the condition, including whether acute or chronic
    • The incidence and prevalence, including in different demographic groups
    • Typical and atypical presentations
    • Recognition of normal variations throughout life
    • Risk factors, including lifestyle, socio-economic and genetic factors
    • Diagnostic features and differential diagnosis
    • Recognition of ‘alarm’ or ‘red flag’ features
    • Appropriate and relevant investigations
    • Interpretation of test results
    • Management, including initial and continuing care, chronic disease monitoring and emergency care
    • Patient and carer information and education
    • Prognosis

    Common and Important Conditions

    • Cancer related pain
    • Chronic Pain
    • Cluster Headache
    • Fibromyalgia
    • Lumbar Disc Disease
    • Mechanical Back Pain
    • Medication overuse headache
    • Migraine
    • Osteoarthritis
    • Peripheral neuropathy
    • Plantar Fascitis
    • Polymyalgia Rheumatica
    • Post herpetic neuralgia
    • Post Operative Pain
    • Radiculopathy
    • Repetitive Strain Injury
    • Rheumatoid Arthritis
    • Tendinopathy
    • Tension Headache
    • Trigeminal Neuralgia

  • Wherever possible learning resources included here are peer reviewed and externally maintained. This is to ensure that trainees have access to quality assured information that is kept up to date.

    Self-Directed 

    Workplace Based Learning

    Workplace-based learning offers a rich environment to develop practical skills in assessing and managing pain in real-world clinical settings. In general practice, trainees encounter a wide spectrum of pain presentations, from acute musculoskeletal injuries and headaches to complex chronic pain syndromes and pain associated with long-term conditions. Through supervised consultations, case-based discussions, and feedback, trainees learn to take a thorough pain history, assess functional impact, explore psychosocial factors, and develop safe, person-centred management plans. Exposure to multidisciplinary input (such as physiotherapy, psychology, or pain clinics) further enhances understanding of holistic care. Managing pain in the workplace setting also allows trainees to reflect on their communication strategies, the appropriate use of medications (including opioids), and the importance of realistic goal setting and continuity of care.

    Day Release

    Day release teaching provides an ideal opportunity to explore the complexities of pain management in a structured and reflective setting. These sessions can cover a range of topics including the assessment of acute vs. chronic pain, red flags, analgesic ladders, non-pharmacological strategies, and the biopsychosocial model. Case-based discussions allow trainees to examine real-life scenarios, share challenges, and consider different approaches to managing persistent pain. Role play and peer feedback can help refine communication skills, particularly when addressing patient expectations, medication concerns, or explaining long-term management plans. Involving guest speakers, such as physiotherapists, psychologists or pain specialists, can further enrich understanding of the causes of chronic pain and multidisciplinary and non-drug approaches to care.

    Registrar Tutorials

    Registrar tutorials offer a focused environment for exploring the assessment and management of pain in a way that’s directly relevant to general practice. These sessions can address key topics such as differentiating between acute and chronic pain, neuropathic vs. nociceptive pain, safe prescribing (including opioid stewardship), and the role of non-pharmacological therapies. Tutorials are ideal for discussing complex cases, reviewing current guidelines, and reflecting on the challenges of managing patient expectations and uncertainty. Practical exercises (such as pain history role plays or medication reviews) can build confidence in clinical decision-making and communication. These sessions also provide a space for registrars to share strategies, explore their own responses to difficult consultations, and reinforce a patient-centred, realistic approach to pain care.

  • Entrustable Professional Activities (EPAs) underpin workplace-based assessment in this curriculum. Each EPA represents an integrated clinical task that General Practitioners must perform safely and independently, assessed through direct or indirect observation in real clinical settings.

    The curriculum and EPA framework are closely aligned: the curriculum defines the required knowledge, skills, and professional behaviours, while EPAs assess their application in practice. Together, they create a coherent approach to developing and demonstrating readiness for independent clinical work.

    The examples show how specific activities within general practice & chapters of the curriculum align with particular EPAs.

     EPA 17: Manage the integration of evidence-based therapeutics into patient care and prescribe and manage medications

    For EPA 17, reviewing opioid therapy in chronic pain demonstrates competence in evidence-based prescribing, evaluating treatment effectiveness, and planning safe tapering where appropriate. A CBD can be used to discuss shared decision-making, risk-benefit considerations, and non-pharmacological alternatives.

    Core Knowledge Test (CKT)

    • Choosing the safest analgesic strategy for chronic pain in an elderly patient.
    • Selecting the correct neuropathic pain medication for first-line use.
    • Managing pain in fibromyalgia

    Clinical Competency Test (CCT)

    • A patient requesting stronger painkillers for long-standing back pain.
    • A patient presenting with migraines.
    • A patient presenting with debilitating knee pain.

    Disclaimer: The examples provided within this section are intended to be indicative only and are included to illustrate how elements of the curriculum may be assessed in the Clinical Competency Test (CCT).

    Examination questions in the CCT test the ability of candidates to integrate knowledge, skills, and professional behaviours across multiple curriculum areas to address the challenges posed by the question.

    The indicative content should therefore be used solely as a general guide as to some of the topics that may be introduced. Actual examination questions will assess a greater depth and complexity of understanding than the illustrative examples provided.

    Please note that a number of CCT questions will require candidates to undertake a physical examination of the simulated patient. In some circumstances, for example in the case of an intimate examination, candidates may be required to display their examination skills through use of a manikin or other device.

  • 1. Mäntyselkä P, Kumpusalo E, Ahonen R, Kumpusalo A, Kauhanen J, Viinamäki H, et al. Pain as a reason to visit the doctor: a study in Finnish primary health care. PAIN. 2001 Jan;89(2):175.