The United Kingdom's chronic pain prescribing landscape has become one of the most contested areas in primary care medicine. With millions of patients on long-term opioids and gabapentinoids that guidelines say shouldn't have been started, a landmark NICE guideline that proved difficult to implement, and death tolls rising in parallel with prescription volumes, the challenge facing GPs is simultaneously clinical, ethical, and political. For AKT candidates, this is a topic that demands both pharmacological precision and critical thinking about evidence.
The Scale of the Problem
Chronic pain is among the most prevalent conditions seen in UK general practice. A systematic review and meta-analysis published in BMJ Open in 2016 by Fayaz and colleagues estimated that between one third and one half of the UK adult population experience chronic pain, with approximately 14% reporting symptoms severe enough to be disabling. That translates, depending on the estimate used, to somewhere between 15 and 28 million adults living with persistent pain. This is not a niche clinical problem. It is the background noise of primary care consultations across the country.
What has developed alongside this burden is a prescribing pattern that has alarmed clinicians and public health authorities in equal measure. A commentary published in the British Journal of General Practice in 2022 noted that in 2017 to 2018, 11.5 million adults in England - representing approximately a quarter of the adult population – received at least one prescription for opioids, gabapentinoids, benzodiazepines, z-drugs, or antidepressants. Prescribing rates of these medications are strongly associated with areas of socioeconomic deprivation, a finding replicated across multiple datasets and one that raises deep questions about whether medication is being used to manage pain or, at least in part, to manage the consequences of poverty and social adversity.
The trajectory of opioid prescribing is particularly striking. Analysis published in The Lancet Psychiatry in 2019 by Curtis and colleagues showed that opioid prescribing in England more than doubled between 1998 and 2018, with the sharpest growth in stronger opioids. During this same period, prescribed opioid-associated deaths in England and Wales increased approximately fourfold between 1993 and 2017. The United Kingdom held the distinction - if that is the right word - of having the world's highest rate of opioid consumption in 2019 according to global pharmacoepidemiological analyses. When commentators began describing a British opioid crisis, they were not being hyperbolic.
The Gabapentinoid Parallel
Running alongside the opioid story, and increasingly entangled with it, is the rise and partial fall of gabapentinoid prescribing. Pregabalin and gabapentin are alpha-2-delta calcium channel ligands, approved in the UK for neuropathic pain, epilepsy, and in the case of pregabalin, generalised anxiety disorder. From the mid-2000s onwards, their prescribing increased dramatically, driven in part by genuine clinical need, in part by off-label use for broader pain indications, and in part by the allure of a non-opioid alternative that carried less stigma.
Research published in The Lancet Regional Health - Europe in 2023 by Ashworth and colleagues demonstrated that the rate of patients newly treated with gabapentinoids tripled between 2007 and 2017 in UK primary care. The data also revealed a concerning prescribing context: gabapentinoids were commonly co-prescribed with opioids in around 60% of cases, with antidepressants in 52%, and with benzodiazepines in 19%. This polypharmacy profile is not incidental - it is epidemiologically lethal. A population-based nested case-control study published in PLoS Medicine in 2017 by Gomes and colleagues demonstrated that gabapentin co-prescribed with opioids substantially increased the risk of opioid-related death. The interaction is pharmacologically coherent: gabapentinoids potentiate respiratory depression in the presence of opioids, and there is evidence they can reverse opioid tolerance, making combinations particularly dangerous at what might otherwise seem like safe individual doses.
An analysis of fatalities associated with gabapentinoids in England between 2004 and 2020, published in the British Journal of Clinical Pharmacology in 2022 by Kalk and colleagues, reported 3,051 deaths in which gabapentinoids were detected. Opioids were co-detected in 92% of cases. Critically, in only two cases was gabapentinoid toxicity alone cited as the cause of death - a finding that highlights how the real risk lies in combination, not in these drugs taken in isolation. The same analysis found that prescribed and illicitly obtained gabapentinoids accounted for broadly similar proportions of deaths, pointing to a significant diversion problem. Pregabalin in particular produces euphoria, sedation and dissociation at higher doses, and has been actively sought as a recreational drug, with The Sunday Times reporting in March 2024 that it carried the fastest-rising death toll of any drug in the UK.
The regulatory response - reclassifying pregabalin and gabapentin as Schedule 3 Class C controlled drugs from April 2019 - was a necessary step, but its impact on prescribing volumes has been modest. Research published in The Lancet Regional Health - Europe by Ashworth and colleagues found that while incident prescribing had peaked and begun to fall before reclassification, prevalent prescribing - that is, the continuing supply to those already on these drugs - changed very little in the months following the policy change. The same picture emerged from a cross-national comparison of Scotland and Northern Ireland published in Expert Review of Clinical Pharmacology in 2025, which found that neither the 2019 reclassification nor the COVID-19 lockdowns produced statistically significant changes in prescribing patterns. Regulatory reclassification, it appears, does not easily interrupt established prescribing relationships.
NICE NG193: A Watershed Moment and Its Discontents
Against this background, the publication of NICE guideline NG193 - Chronic Pain (Primary and Secondary) in Over 16s: Assessment of All Chronic Pain and Management of Chronic Primary Pain - in April 2021 was genuinely remarkable. Its central pharmacological recommendation was nothing short of radical: do not offer any conventional analgesic medication for chronic primary pain. This included paracetamol, NSAIDs, opioids, gabapentinoids, benzodiazepines, corticosteroids, local anaesthetics, ketamine, and cannabis-based products. The sole pharmacological option recommended for consideration was certain antidepressants, specifically low-dose amitriptyline, duloxetine, and - with caveats - fluoxetine, on the basis that they appeared to offer some evidence of benefit in modulating pain processing centrally.
The guideline defined chronic primary pain as pain lasting more than three months that either has no clear underlying condition, or where the pain and its associated distress and functional impact are out of proportion to observable pathology. This category encompasses fibromyalgia, chronic widespread pain, chronic primary headache, and chronic primary pelvic pain, and is estimated to affect between 1% and 6% of the population in England. For chronic secondary pain - pain attributable to an identifiable underlying condition such as osteoarthritis, rheumatoid arthritis, or endometriosis - the guideline directed clinicians to condition-specific guidance rather than NG193 itself. This distinction between primary and secondary chronic pain, while clinically important, is frequently blurred in real-world practice, and significant overlap exists in the same individual.
The non-pharmacological interventions NG193 recommended were exercise programmes, psychological therapies including acceptance and commitment therapy and cognitive behavioural therapy, and acupuncture. The evidence base for all three was acknowledged to be limited and imperfect, but was judged superior to the evidence for pharmacotherapy in this specific population.
The response from the profession was polarised. Some clinicians welcomed the guideline as a long-overdue reckoning with the harms of analgesic polypharmacy - an evidence-based platform from which to have difficult but honest conversations with patients who had been accumulating prescriptions for years without meaningful benefit. Others were deeply critical. The Faculty of Pain Medicine published formal concerns about the guideline's methodology shortly after its release, arguing that NICE had failed to consider relevant Cochrane reviews and that the characterisation of the evidence base was too narrow. An international commentary published in Pain Reports in 2021 raised three major objections, including the claim that NICE had incorrectly asserted there was no evidence for treatments for chronic primary pain, noting that this was partly a terminology problem - studies published before the ICD-11 chronic pain classification was established used different diagnostic labels, and excluding them on that basis distorted the evidence review.
A particularly sharp critique concerned the guideline's position on antidepressants. While recommending them as the sole pharmacological option, NG193 did not engage substantively with growing concerns about antidepressant withdrawal, long-term dependency, and adverse effects - concerns documented in the 2019 Public Health England review of dependence and withdrawal associated with prescribed medicines. Critics noted an internal inconsistency: a guideline expressing concern about iatrogenic dependency in the context of opioids and gabapentinoids seemed less alert to the same risk profile for antidepressants.
The Deprescribing Challenge Nobody Solved
Perhaps the most practically significant gap in NG193 was identified immediately by clinicians working in primary care: the guideline recommended against initiating these medications but provided no framework for what to do with the millions of patients already taking them. Deprescribing long-term opioids and gabapentinoids in the context of established dependency and chronic pain is one of the most technically and ethically complex tasks in general practice. These patients exist on a spectrum from those who would genuinely welcome a supported reduction plan to those for whom abrupt or rapid withdrawal would be medically dangerous and who have already tried to reduce without success.
A cross-sectional study of community-dwelling patients with chronic pain mapped against NG193, published in BMC Psychology in 2022, found that despite the guideline, 47% of participants with chronic primary pain were still using opioids. This is not a failure of guideline dissemination. It reflects a structural reality: the services capable of delivering evidence-based alternatives - specialist pain psychology, supervised group exercise, acupuncture - are not available at the scale the guideline's implementation requires. The NHS Long Term Plan embedded social prescribing, and first-contact physiotherapists are increasingly present in primary care, but the capacity to absorb the volume of complex chronic pain patients that NG193 implies should be transitioned away from pharmacological management does not currently exist.
Deprivation, Pain, and the Medicalisation Debate
The social geography of chronic pain prescribing adds a dimension that purely clinical analyses risk missing. Study after study confirms that opioid and gabapentinoid prescribing is highest in areas of greatest socioeconomic deprivation, even after adjusting for chronic pain prevalence. A retrospective cohort study published in PLOS Medicine in 2020 by Colvin and colleagues found that the adjusted odds of long-term opioid use in opioid-naïve patients were highest in the North West and Yorkshire - regions that also carry higher burdens of deprivation - and that this north-south gradient persisted after controlling for case mix. Scotland carries a particularly acute version of this pattern: between 2017 and 2018, Scotland had drug-related deaths approximately three times higher per million of population than England and Wales.
A BJGP editorial from 2020 argued that adversity and distress had been medicalised in the UK, with prescriptions serving as surrogates for social and psychological support that the system was unable to provide. This framing is uncomfortable but difficult to dismiss. Pain is genuinely more prevalent in deprived communities, and treatment by prescription is not inherently wrong. But if the prescription of opioids to a person whose pain is inextricably bound up with housing insecurity, unemployment, trauma and isolation produces dependency without addressing any of the underlying causes of distress, it may represent iatrogenic harm at a population level.
What This Means for the AKT
Chronic pain is a high-yield AKT topic that rewards careful pharmacological understanding. Candidates should be clear on the distinction between chronic primary and chronic secondary pain as defined in NG193, and should understand that the NICE recommendation against opioids, gabapentinoids, and conventional analgesics applies to chronic primary pain specifically, not to secondary pain where condition-specific guidance takes precedence. The mechanisms of gabapentinoid action - binding to the alpha-2-delta subunit of voltage-gated calcium channels, reducing excitatory neurotransmitter release - explain both their analgesic properties and their abuse potential. The interaction between gabapentinoids and opioids producing respiratory depression and reversing opioid tolerance is a key pharmacokinetic and pharmacodynamic interaction that has featured in prescribing safety guidance.
Candidates should know that both gabapentin and pregabalin are Schedule 3 Class C controlled drugs since April 2019, and understand the prescribing restrictions this entails, including the 28-day prescription limit and the requirement that prescriptions be signed and handwritten or generated by approved electronic systems. The antidepressants recommended in NG193 for consideration in chronic primary pain - amitriptyline, duloxetine, and conditionally fluoxetine - each have distinct mechanisms and side effect profiles, and questions distinguishing their appropriate application are well within AKT scope. The capacity to recognise when a patient presenting with escalating analgesic use for chronic pain warrants a structured review, and to articulate the evidence-based alternatives, is precisely the clinical reasoning the MLA is designed to assess.
The UK opioid and gabapentinoid story does not have a clean resolution. It is a crisis of prescribing culture, service capacity, evidence interpretation, and social policy compressed into the space of a ten-minute general practice consultation. Understanding all of those layers is, ultimately, what good primary care medicine requires.