Mastering NICE Chronic Pain Guidelines for SCE Geriatrics Success

Why Chronic Pain Matters in SCE Geriatrics

Chronic pain is a frequent, high-impact presentation in older adults and a staple topic in the SCE Geriatrics exam. It’s not just about controlling pain intensity—it’s about safe prescribing, assessing function, managing comorbidities, and shared decision-making.

The NICE guideline CG177 (Neuropathic pain) and the broader chronic pain recommendations (updated through NICE) form the backbone of safe, effective management. The exam will test your ability to identify pain type, select first-line therapies, and recognize red flags for referral.

Assess and Categorize the Pain

• Clarify the pain phenotype:

  • Nociceptive (e.g., osteoarthritis, musculoskeletal)

  • Neuropathic (burning, shooting, allodynia; think diabetic neuropathy, postherpetic neuralgia)

  • Nociplastic (central sensitization; fibromyalgia-like)

• Red flags requiring urgent action:

  • New severe headache or visual changes → giant cell arteritis

  • Weight loss, night pain, fever, or history of malignancy

  • Focal neurology or progressive deficit

  • Signs of infection, fracture, or acute abdomen

Shared Decision-Making and Goals

• Set SMART functional goals (e.g., walk 200 m with <3/10 pain, sleep through the night).

• Discuss risks and benefits; consider falls risk, renal/hepatic impairment, and polypharmacy.

Stepwise Management (NICE-aligned)

1) Non-pharmacological first-line for all types

• Physical activity tailored to ability (strength, balance, aerobic).

• Weight management if applicable.

• Psychological therapies (CBT, ACT) for pain coping.

• Heat/cold, TENS (as adjunct), and targeted physiotherapy.

2) Pharmacological options by pain type

Nociceptive (e.g., OA)

• Regular paracetamol (caution in liver disease).

• Topical NSAID (e.g., diclofenac gel) where appropriate.

• Oral NSAIDs only after risk assessment (GI, renal, cardiovascular); add PPI if used.

• Consider duloxetine for chronic musculoskeletal pain in older adults.

Neuropathic

• First-line: amitriptyline or gabapentin/pregabalin.

  • Start low, go slow in older adults; monitor sedation, dizziness, falls.

• If inadequate response, switch within class or to other first-line.

• Avoid opioids as first-line; consider tramadol/codeine with caution in select cases.

Nociplastic

• Duloxetine or amitriptyline.

• Multimodal approach: graded exercise, CBT, sleep hygiene.

3) Opioid stewardship

• Not first-line for chronic non-cancer pain.

• If used (rare), consider low-dose weak opioid (e.g., codeine or tramadol) with clear goals, informed consent, and a stop date.

• High-dose opioids: reassess regularly; consider taper if benefits do not outweigh harms.

• Naloxone education for patients at risk of overdose.

4) Add-ons and second-line

• Topical capsaicin or lidocaine for localized neuropathic pain.

• Interventional options in selected cases (e.g., facet joint injections) but only after conservative measures and imaging correlation.

Safety in Older Adults

• Check renal/hepatic function; adjust doses.

• Screen for constipation; prescribe bowel regimen with opioids.

• Review falls risk and cognitive effects (sedation, confusion).

• Perform medication reconciliation; deprescribe where possible.

Referral and Escalation

• Persistent severe pain despite optimized first-line treatment

• New neurological deficits or red flags

• Suspected inflammatory/arthritic or malignant causes

SCE OSCE Tip: Structure Your Answer

• Start with a concise history and pain phenotype identification.

• State the stepwise plan (non-pharmacological → first-line meds → second-line).

• Explicitly address risks in older adults and monitoring plan.

• End with red flags and referral criteria.

Quick Reference Table

High-Yield SCE Pearls

• Neuropathic pain first-line is never an opioid in the long term.

• Always pair an NSAID with a PPI in older adults if used orally.

• Duloxetine is useful for chronic MSK pain and neuropathic pain.

• Set functional goals; reassess at 4–8 weeks; document benefits vs. harms.

• In falls-risk patients, prefer less sedating agents and monitor closely.

Use this framework to demonstrate safe, guideline-driven care—precisely what SCE examiners are looking for in chronic pain scenarios.