Chronic non-cancer pain: the biopsychosocial approach in AU general practice

Chronic non-cancer pain (CNCP) is the most common reason Australian adults live with disability. It affects roughly one in five people — about five million Australians — and accounts for a substantial proportion of general practice consultations, often intertwined with mental health conditions, sleep disorders, and functional decline. The older biomedical framing — find the lesion, fix the lesion — fails this patient population. The Faculty of Pain Medicine ANZCA, Australian Pain Society, and Pain Australia all converge on a biopsychosocial framework as the necessary starting point.

The clinical definition is pain persisting beyond expected healing time, typically three months or more, in the absence of active malignancy. In practice, the boundary between chronic primary pain (pain as the condition itself — fibromyalgia, complex regional pain syndrome) and chronic secondary pain (pain as a feature of another condition — neuropathic pain from diabetes, musculoskeletal pain from degenerative joint disease) is often blurred. Importantly, the biological, psychological, and social factors maintaining the pain are similar across these categories.

A. Core clinical — the AU general practice framework

Assessment — the biopsychosocial history

A comprehensive pain history goes beyond standard medical history. RACGP guidance on prescribing drugs of dependence emphasises assessing:

• Pain history — onset, mechanism, location, character, severity (0–10 NRS), pattern, aggravating and relieving factors, prior treatments and responses
• Functional impact — work, activities of daily living, sleep, mood, relationships, recreation
• Yellow flags — fear-avoidance of activity, catastrophising (“I’ll cause permanent damage”), low self-efficacy, unrealistic expectations of cure, compensation and work issues
• Comorbidities — depression and anxiety (~50% prevalence, bidirectional with pain), sleep disturbance, obstructive sleep apnoea, substance use disorder, obesity
• Social context — family beliefs about pain, work demands, financial stress, compensation status
• Suicidality — chronic pain approximately doubles the baseline risk; screen at every comprehensive review

Validated tools: PHQ-9 (depression), GAD-7 (anxiety), painDETECT (neuropathic component screen), STarT Back (stratification for low back pain), Brief Pain Inventory (functional impact), Opioid Risk Tool (before opioid prescribing).

The multimodal biopsychosocial treatment model

eTG Pain and RACGP guidance align on the same first-line framework:

1. Pain neuroscience education Explaining the biology of central sensitisation — not as dismissive, but as the scientifically accurate explanation for why pain has persisted — reduces catastrophising and improves engagement with active rehabilitation. The message: “the volume knob on your nervous system’s pain signal is turned up; this is biology, not weakness; movement and psychological strategies are how we help your nervous system recalibrate.” Resources: Pain Australia, PainHealth (UWA), Lorimer Moseley’s Explain Pain series.

2. Active rehabilitation — cornerstone Exercise is first-line. Exercise type matters less than sustainability and patient engagement. Aerobic activity, strength training, stretching, aquatic exercise — all have evidence; the best is what the patient will do consistently. Graded exposure addresses fear-avoidance by progressive return to activities the patient is avoiding. Physiotherapy and exercise physiology are the primary referrals under GPCCMP allied-health provisions.

3. Psychological therapy Williams et al. (Cochrane 2020) confirm CBT for chronic pain improves function, mood, and disability, with effects maintained at follow-up. Acceptance and Commitment Therapy (ACT) has comparable evidence. Both are accessible via Mental Health Care Plan (Better Access) with a clinical psychologist. Mindfulness-based stress reduction also has solid evidence base for chronic pain.

4. Multidisciplinary pain management programs For severe, disabling CNCP — particularly where work is affected, mood comorbidity is significant, or high-dose opioids are in the picture — structured multidisciplinary pain programs combining medical, psychological, physiotherapy, and occupational therapy inputs deliver the strongest evidence. Kamper et al. (Cochrane 2014) showed superior outcomes for function, mood, and return to work compared to single-discipline management.

5. Pharmacotherapy — adjunctive, condition-specific eTG Pain and AMH support a rational stepwise approach:

• Paracetamol — first-line for most CNCP; modest effect; safe in renal and cardiac disease; max 4 g/day (3 g in elderly or hepatic impairment)
• Topical NSAIDs, capsaicin, lignocaine — for localised neuropathic or musculoskeletal pain; avoids systemic toxicity
• Oral NSAIDs — lowest effective dose for the shortest time; GI, renal, and cardiovascular risks accumulate with chronic use
• TCAs (amitriptyline, nortriptyline) — 10–75 mg at night; neuropathic pain, fibromyalgia; modest evidence; anticholinergic side effects; falls risk in elderly
• SNRIs (duloxetine) — 30–60 mg daily; neuropathic pain, fibromyalgia, osteoarthritis with comorbid depression; PBS Authority for depression and diabetic neuropathy
• Pregabalin / gabapentin — reserve for true neuropathic pain (diabetic neuropathy, post-herpetic neuralgia); Mathieson et al. (NEJM 2017) showed pregabalin no better than placebo for sciatica; pregabalin requires PBS Authority, SafeScript / RTPM monitoring, and falls counselling

6. Comorbidity management Depression and anxiety need their own treatment, not just pain management as a proxy. Sleep disturbance needs CBT-I first (see the insomnia page). Obstructive sleep apnoea, when present, warrants its own pathway — CPAP substantially improves pain outcomes in OSA-comorbid CNCP. Smoking cessation independently improves chronic pain outcomes.

B. Evidence appraisal — opioids and the contested treatments

The opioid evidence

The SPACE trial (Krebs, JAMA 2018) is the definitive evidence. Over twelve months, opioids were no better than non-opioid medications for back, hip, or knee pain on the primary outcome measure, and caused significantly more adverse effects. This finding — combined with evidence on dependence, overdose, opioid-induced hyperalgesia, endocrine suppression, and cognitive effects — underpins the Faculty of Pain Medicine ANZCA position firmly against initiating long-term opioids for CNCP.

If a time-limited opioid trial is undertaken — in carefully selected patients after exhausting non-opioid options — the approach should be: short duration, documented goals with exit strategy, ≤50 mg morphine equivalent daily, SafeScript / RTPM check at every prescription, and absolute avoidance of concurrent benzodiazepine or Z-drug prescribing.

Gabapentinoids — the overprescription problem

Pregabalin and gabapentin are RTPM-monitored in Australia for good reason. Mathieson et al. showed pregabalin was no better than placebo for sciatica. Meta-analyses confirm limited benefit in chronic non-neuropathic pain. Both agents carry real risks: sedation, falls, dependence (Schedule 4 controlled), and significant overdose risk when combined with opioids. Prescribing should be reserved for confirmed neuropathic indications.

Medicinal cannabis

Not routinely recommended per NICE NG193 or AU primary tier. Mücke et al. (Cochrane 2018) found sparse evidence, modest effect sizes comparable to placebo in many comparisons, and clinically significant adverse effects including cognitive impairment and driving hazard. The TGA Special Access Scheme (Category B) and Authorised Prescriber pathways provide legal access for appropriately selected patients after guideline-aligned treatment has been tried. Counsel on driving impairment — it is both a safety issue and a legal one.

C. SafeScript, opioid de-prescribing, and medico-legal obligations

SafeScript and RTPM

Real-time prescription monitoring is now operational in all Australian states and territories. The system must be checked before prescribing opioids, pregabalin, benzodiazepines, and Z-drugs. It identifies concurrent prescribers, high-risk dose escalation, and dangerous combinations — most critically, opioid plus benzodiazepine co-prescribing, which dramatically increases overdose mortality.

Existing patients on long-term opioids warrant a structured review: establish whether the opioid is achieving meaningful functional benefit, educate on harms and alternatives, and begin a shared, planned taper if possible. Buprenorphine (Norspan patch, Subutex sublingual, Sublocade depot) is an important option for transitioning patients away from high-dose full-agonist opioids — the partial-agonist ceiling effect substantially reduces overdose risk. Buprenorphine initiation for pain de-prescribing is best done in collaboration with specialist pain medicine or addiction medicine.

Schedule 8 authorities

In Victoria, ongoing Schedule 8 opioid prescribing beyond two months or above specific morphine equivalent dose thresholds requires a Schedule 8 Permit from the Department of Health. Similar frameworks apply in other states. These requirements should be checked for each jurisdiction. PBS Authority codes apply for most strong opioids for non-cancer pain.

D. Australian operations

MBS pathways

Standard consultations under MBS items 23, 36, and 44 cover most chronic pain reviews. Chronic non-cancer pain qualifies for a GP Chronic Condition Management Plan (GPCCMP) under items 965 and 967, enabling referral to physiotherapy or exercise physiology, clinical psychology (Better Access), and dietitian where obesity is relevant. Mental Health Care Plan items 2700, 2715, 2717 are appropriate when depression or anxiety is the primary or co-primary presentation.

Home Medicines Review (item 900) with an accredited pharmacist is valuable for reviewing polypharmacy and opioid burden. Telehealth video and phone consultations (items 92029 and 92060) suit ongoing pain management review and de-prescribing follow-up, particularly for patients with mobility limitations.

Workers’ compensation (iCare NSW, WorkCover VIC/QLD) and DVA Gold/White Card cover pain management for work-related and service-related conditions respectively. NDIS may be relevant for severely functionally impaired patients.

PBS

Paracetamol is on PBS for chronic pain (some formulations) and available OTC. Topical diclofenac gel and oral NSAIDs are PBS. Tramadol is general schedule Schedule 4. Strong opioids require PBS Authority. Pregabalin requires PBS Authority for neuropathic pain refractory to first-line agents. Duloxetine requires PBS Authority for depression and restricted Authority for diabetic neuropathy. Medicinal cannabis is not PBS-listed; TGA SAS or Authorised Prescriber pathway applies.

E. Special populations

Elderly patients. Falls risk from opioids, gabapentinoids, and sedating antidepressants is substantially elevated. Anticholinergic burden from amitriptyline is problematic in this age group. Prefer physiotherapy, exercise, and paracetamol as first-line; use pharmacotherapy conservatively.

Patients with comorbid substance use disorder. Opioid prescribing is particularly high-risk; detailed Opioid Risk Tool or SOAPP assessment is necessary if considered. Buprenorphine/naloxone (Suboxone) for opioid use disorder also addresses pain in many patients. Addiction medicine or pain medicine collaboration is appropriate.

Compensation and medico-legal context. Disputed compensation claims, income insecurity, and adversarial medico-legal environments are strong yellow flags for chronicity. Work with the treating team to address psychosocial barriers; independent medical examinations require careful documentation and neutrality.

Pregnancy. Most pharmacotherapy for chronic pain is avoided in pregnancy. Physiotherapy, hydrotherapy, and psychological approaches are first-line. Short-term paracetamol at minimum effective dose has the best safety profile.

When to escalate

Refer to specialist pain medicine when:

• Chronic pain is severe and disabling despite a complete multimodal trial over three to six months
• High-dose opioid de-prescribing or buprenorphine transition is needed
• Complex regional pain syndrome, post-surgical persistent pain, or atypical pain syndromes require specialist assessment
• Interventional procedures (epidural, radiofrequency ablation for confirmed facet-mediated pain) are under consideration
• Workers’ compensation or DVA medico-legal complexity requires independent assessment
• SafeScript findings indicate high-risk prescribing patterns requiring specialist input

What this article is and is not

This is general health information drawn from current Australian guidelines — RACGP, Faculty of Pain Medicine ANZCA, Australian Pain Society, eTG Pain, and AMH. It does not constitute personal medical advice. Decisions about pain management, including pharmacotherapy, are made with your own GP and treating clinicians who know your full history.

For patient-friendly AU resources: Pain Australia, PainHealth (UWA), HealthDirect — Chronic pain, Better Health Channel, Tame the Beast — pain education.

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Sources cited

1. Faculty of Pain Medicine ANZCA — Statement on Opioids in Chronic Non-Cancer Pain
2. Australian Pain Society
3. RACGP — Prescribing drugs of dependence Part C2: opioids in pain
4. Therapeutic Guidelines (eTG) — Pain
5. Australian Medicines Handbook
6. Pain Australia
7. PainHealth — UWA
8. HealthDirect — Chronic pain
9. Better Health Channel — Chronic pain
10. Krebs — SPACE trial (JAMA 2018)
11. Williams — Psychological therapy for chronic pain (Cochrane 2020)
12. Kamper — Multidisciplinary biopsychosocial rehabilitation (Cochrane 2014)
13. Mathieson — Pregabalin for sciatica (NEJM 2017)
14. Mücke — Cannabis-based medicines for chronic neuropathic pain (Cochrane 2018)
15. NICE NG193 — Chronic pain in over 16s