Adult Chronic Pain Assessment
Adults with pain >3 months or beyond normal healing. Not for cancer pain, sickle cell disease, palliative or end-of-life care.
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Family MedicineManagement
Chronic Pain Management (CDC 2022 Guidelines)
Chronic Pain Management (CDC 2022 Guidelines): Adult Chronic Pain Assessment → Comprehensive Pain Evaluation → Classify Pain Type → Non-Drug Therapy Fir...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action Comprehensive Pain Evaluation
Find the cause, red flags and impact
- Red flags (cancer, infection, fracture, cauda equina, progressive neurological deficit): investigate or refer now
- Pain history: site, intensity (0-10), quality, timing; prior treatments and response. Function: work, daily activities, sleep; set pain and function goals with the patient
- Screen for depression, anxiety and suicide risk; ask about alcohol and other substance use
- Medicines list: benzodiazepines, gabapentinoids, other sedatives, other opioids
03Action Classify Pain Type
Guides drug choice in the next steps
- Nociceptive: mechanical or inflammatory (OA, muscular back pain)
- Neuropathic: burning, shooting (diabetic neuropathy, post-herpetic neuralgia)
- Nociplastic: central sensitisation (fibromyalgia)
- Mixed: features of more than one type
04Action Non-Drug Therapy First (All Patients)
Foundation of chronic pain care; continue alongside any medicine
- Exercise or exercise therapy (physiotherapy); weight loss for knee OA
- Cognitive behavioural therapy or other psychological therapy
- Mindfulness, yoga or tai chi
- Manual therapy, massage or acupuncture for selected conditions
05Warning Check Cautions Before Non-Opioid Medicines
Pregnancy: avoid oral NSAIDs from 20 weeks; get specialist advice before any pain medicine.
- NSAIDs: avoid or use caution in GI bleeding, kidney disease, heart failure, cardiovascular disease, anticoagulant use, older age, pregnancy 20 weeks or more
- TCAs: avoid in heart conduction disease; toxic in overdose; confusion and falls in older adults. Duloxetine: avoid in chronic liver disease, heavy alcohol use or eGFR <30 mL/min
- Gabapentinoids: reduce dose in kidney impairment; misuse risk. Tramadol with an SSRI, SNRI or TCA: serotonin syndrome
06Action Non-Opioid Medicines (Match to Pain Type)
Preferred over opioids. Check the cautions in the step before first.
- Nociceptive: NSAID (topical first where possible), lowest dose, shortest time
- OA or back pain: duloxetine is an option. Paracetamol has limited benefit and is not first-line in OA
- Neuropathic: low-dose TCA (amitriptyline), duloxetine, or pregabalin/gabapentin; topical lidocaine or capsaicin for local pain
- Nociplastic (fibromyalgia): exercise first; then amitriptyline, duloxetine or pregabalin. Opioids not recommended
07Decision Pain and Function Still Inadequate: Opioid Trial?
Only if non-drug and non-opioid options are inadequate or contraindicated, and expected benefit for pain and function outweighs risk. First agree pain and function goals, and how opioids will be stopped if benefit does not outweigh risk. Fibromyalgia or headache: opioids not recommended. Active opioid use disorder: treat OUD instead.
- If Yes
08Warning Opioid Trial Chosen: Check High-Risk Factors First
These patients need a lower dose, extra precautions or specialist advice
- Benzodiazepines, gabapentinoids, alcohol or other sedatives: risk of fatal respiratory depression. Avoid combining where possible
- Moderate or severe sleep apnoea: avoid opioids where possible. Age 65 or more, kidney or liver impairment: lower dose, closer review
- Pregnancy or planning pregnancy, past overdose or substance use disorder: specialist advice before starting. Depression or other mental illness: optimise its treatment first; review more often
09Action Opioid Trial: Start Low
Adults, opioid-naive. Immediate-release opioid only. Tramadol with an SSRI, SNRI or TCA: serotonin syndrome risk.
- Immediate-release, not extended-release or long-acting
- Lowest effective dose: often about 5-10 MME (oral morphine equivalent) per dose, or 20-30 MME/day
- Before any increase to 50 MME/day or more: pause and reassess benefit and harm
- Offer take-home naloxone; check real-time prescription monitoring; review in 1-4 weeks
10Action Ongoing Review (All Patients)
Required for everyone on this pathway
- Reassess pain, function and harms 1-4 weeks after starting an opioid or any dose increase, then every 3 months or more often
- Higher risk (50 MME/day or more, sedatives, mental illness, substance use disorder, past overdose): review more often than every 3 months
- Check real-time prescription monitoring before each opioid prescription. Consider urine drug testing; discuss it with the patient first
- Screen for opioid use disorder (DSM-5 criteria)
11Decision Signs of Opioid Use Disorder?
Craving, loss of control, continued use despite harm
- If Yes
12Warning Signs of OUD: Offer OUD Treatment
Do not stop opioids abruptly. Detoxification alone is not recommended. Keep treating pain with non-drug and non-opioid care, and keep reviewing.
- Offer buprenorphine (start in withdrawal or by low-dose induction) or methadone via the opioid treatment program
- Naltrexone only after 7-10 opioid-free days (otherwise severe withdrawal); specialist-led
- Offer take-home naloxone; refer to addiction medicine if complex
- Path rejoins step 10Shared downstream outcome
If No13Decision No OUD Signs: Pain and Function Goals Met?
Goals met with acceptable side effects
- If Yes
14Outcome Goals Met: Continue Current Plan
Lowest effective dose; keep non-drug therapy; keep reviewing
If No15Action Goals Not Met or Harms: Change the Plan
Then return to ongoing review
- Add or intensify non-drug therapy; address psychosocial factors
- Change or rotate non-opioid medicines
- On opioids without benefit: taper slowly (about 10% per month or slower if on opioids for 1 year or more); do not stop abruptly. Serious mental illness or suicide risk: get mental health advice before the taper
- Refer to a pain medicine service if complex
- Path rejoins step 10Shared downstream outcome
If No16Action No Opioid Trial: Optimise Non-Opioid Care
Continue non-drug therapy and non-opioid medicines; active OUD: offer OUD treatment. Then ongoing review.
- Path rejoins step 10Shared downstream outcome
Guideline Source
CDC Clinical Practice Guideline for Prescribing Opioids for Pain 2022
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Opioid-naive initiation only; for patients already on long-term opioids, tapering and rotation are summarised, not detailed
- Based on the US CDC 2022 guideline: Australian state rules for Schedule 8 opioid prescribing (permits, authorities) are not covered; follow local rules
- Adults only; not for cancer pain, sickle cell disease, palliative or end-of-life care
- Interventional procedures not detailed
- Complex regional pain syndrome not specifically addressed
- Opioid use disorder treatment abbreviated; follow local opioid treatment program rules
Contraindicated Populations
pediatriccancer painsickle cell diseasepalliative or end-of-life care
Applicable Regions
USAUUKEU
AU: Hydrocodone is not on the ARTG. Real-time prescription monitoring (e.g., SafeScript, QScript) is mandatory before prescribing in some states (Victoria since April 2020). Take-home naloxone is free through the national program. Australian duloxetine product information lists depression and anxiety only, so use for pain is off-label. Pregabalin is TGA-approved for neuropathic pain, not fibromyalgia. Australian dose term: oral morphine equivalent daily dose (oMEDD).
UK: NICE NG193 (2021) differs: it advises against starting opioids, gabapentinoids, NSAIDs or paracetamol for chronic primary pain.
US: CDC 2022 opioid prescribing guideline.
Version 2Next review: 2027-09-30
Next steps
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Related Resources
Frequently Asked Questions
What is the Chronic Pain Management (CDC 2022 Guidelines)?
The Chronic Pain Management (CDC 2022 Guidelines) is a management clinical algorithm for Family Medicine. It provides a structured decision tree to guide clinical decision-making, based on CDC Clinical Practice Guideline for Prescribing Opioids for Pain 2022.
What guideline is the Chronic Pain Management (CDC 2022 Guidelines) based on?
This algorithm is based on CDC Clinical Practice Guideline for Prescribing Opioids for Pain 2022 (DOI: 10.15585/mmwr.rr7103a1).
What are the limitations of the Chronic Pain Management (CDC 2022 Guidelines)?
Known limitations include: Opioid-naive initiation only; for patients already on long-term opioids, tapering and rotation are summarised, not detailed; Based on the US CDC 2022 guideline: Australian state rules for Schedule 8 opioid prescribing (permits, authorities) are not covered; follow local rules; Adults only; not for cancer pain, sickle cell disease, palliative or end-of-life care; Interventional procedures not detailed; Complex regional pain syndrome not specifically addressed; Opioid use disorder treatment abbreviated; follow local opioid treatment program rules. Individual patient factors may require deviation from these recommendations.
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