Chronic Non-Cancer Pain

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Click here to access the Primary_Healthcare_Chapter_20_Pain_with_supporting_NEMLC_Report_2025-9_Review_Version_1.0_(26_February_2026)

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Description

General Measures

Medicine Treatment

Referral

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R52.1/R52.2/R52.9

DESCRIPTION

Pain is defined as chronic when it is present for more than 3 months.

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• It can arise from:
  • Tissue damage (nociceptive pain), e.g. arthritis, lower back pain, pleuritic pain;
  • Injury to nerves (neuropathic pain) e.g. post herpetic neuralgia (pain following shingles), trigeminal neuralgia, diabetic neuropathy, HIV related peripheral neuropathy, drug induced peripheral neuropathy, or phantom limb pain;
  • Pain experienced in the absence of tissue damage, inflammation and nerve damage (central pain), e.g. fibromyalgia, irritable bowel syndrome. 

GENERAL MEASURES

• Assess pain severity, functional status, medication use including self-medication, co-morbid illnesses, etc.
• Actively look for concomitant depression and anxiety/somatoform pain disorders.
• Counsel on lifestyle adjustments.
• Refer for occupational therapy and physiotherapy as appropriate.
• Address psycho-social problems e.g., stress, anxiety, sleep disturbances.

MEDICINE TREATMENT

• The principles are the same as with cancer pain relief. Analgesics should be given by mouth, regularly, in a stepwise manner to ensure adequate relief.
• Neuropathic and central pain are best treated with analgesics in addition to tricyclic antidepressants.
• It is useful to combine different classes of analgesics for the additive effects, depending on pain severity.

Mild pain:

To manage chronic non-cancer conditions such as genetic conditions, nerve damage pain, chronic musculoskeletal pain, and chronic abdominal pain.

Children

• Paracetamol, oral, 15 mg/kg/dose 6 hourly when required. See dosing table

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Adults

• Paracetamol, oral, 500 mg–1 g, 4–6 hourly as required (to a maximum of 4 g in 24 hours)
  • Maximum dose: 15 mg/kg/dose.

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Pain associated with inflammation: 

Children

See the Paediatric Hospital STGs and EML, Acute Pain.

Adults

• NSAIDs, e.g.: 
• Ibuprofen, oral, 400 mg, 8 hourly with or after a meal.

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OR

Combine paracetamol and ibuprofen at the above dosages. 

Moderate pain:

Adults

If still no relief to simple analgesics (paracetamol and/or ibuprofen), as above

 ADD

• Tramadol, oral, 50–100mg, 6 hourly as a starting dose (Doctor prescribed).
  • May be increased to a maximum daily dose of 400 mg.

Adjuvant therapy:

Adults

In addition to analgesia as above:

• Amitriptyline, oral, 10 mg at night (Doctor initiated).
  • Titrate up to a maximum of 75 mg at night.

LoE:IVb²¹

Under-recognition of pain and under-dosing of analgesics is common in chronic pain. Analgesics should be given regularly rather than only when required in patients with ongoing pain.

REFERRAL

• Pain requiring strong opioids.
• Pain requiring definitive treatment for the underlying disease.
• Conditions difficult to treat e.g. Complex Regional Pain Syndrome (CRPS) and post-herpetic neuralgia.
• All children.

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-2024_Version 1.0_07 November 2024

Chapter 20: Pain_20.3 Chronic Non-Cancer Pain