Chronic pain — defined as pain persisting beyond the normal tissue healing time, typically longer than three months — affects an estimated 28 million adults in the UK according to the British Pain Society. Community pharmacy is often the first and most frequently visited healthcare setting for people seeking pain relief, and pharmacists manage more OTC analgesic queries than any other professional group.

Yet chronic pain OTC management is not straightforward. The evidence base for long-term OTC analgesia is weaker than many patients assume, the risks of prolonged use are real, and the boundary between self-care and GP referral requires clinical judgement.

The OTC analgesic options

Paracetamol

Paracetamol remains the recommended first-line analgesic for many chronic pain conditions according to NICE, though recent evidence has challenged its efficacy for some indications:

• Osteoarthritis. NICE guideline NG226 now states that paracetamol should NOT be routinely offered for osteoarthritis, based on meta-analyses showing only marginal benefit over placebo. However, individual patients may still find it helpful, and it remains appropriate to try before escalating.
• Chronic low back pain. Similar evidence: the Paracetamol for Low-Back Pain (PACE) trial found no difference between paracetamol and placebo for acute low back pain recovery, and NICE CG59 (now NG59) does not recommend paracetamol for chronic low back pain.
• Other chronic pain. Paracetamol may still be useful as a component of multimodal analgesia — taken regularly alongside other measures rather than as a standalone treatment.

Key counselling: Maximum 4g per day in adults. Check for paracetamol in combination products (cold and flu remedies, co-codamol, Syndol). Advise patients that paracetamol works best when taken regularly rather than as-needed for chronic pain.

Oral NSAIDs

Ibuprofen (up to 1200mg/day OTC) and naproxen (not available OTC in the UK except in some combination products) offer better evidence for chronic musculoskeletal pain than paracetamol. However, their OTC availability is limited by safety concerns:

• Gastrointestinal risk. Long-term NSAID use increases the risk of peptic ulceration and GI bleeding. Patients over 65, those with a history of GI problems, or those taking aspirin, corticosteroids or anticoagulants should use oral NSAIDs only on prescriber advice.
• Cardiovascular risk. All NSAIDs (except naproxen at low doses) increase cardiovascular risk with prolonged use. The MHRA advises using the lowest effective dose for the shortest possible time.
• Renal risk. NSAIDs can impair renal function, particularly in patients already taking ACE inhibitors or diuretics — the so-called "triple whammy" combination.

Pharmacy counselling for chronic NSAID users: ask how long they have been buying ibuprofen OTC. If the answer is "months" or "years," a GP review is appropriate to assess whether a prescription NSAID with gastroprotection, or an alternative approach, would be safer.

Topical NSAIDs

Topical diclofenac and ibuprofen gels offer localised pain relief with substantially lower systemic exposure than oral NSAIDs. NICE recommends topical NSAIDs as first-line pharmacological treatment for osteoarthritis of the knee and hand — ahead of oral analgesics.

For detailed comparisons, see: Topical Diclofenac vs Ibuprofen Gels Compared and Topical NSAID Gels for Musculoskeletal Pain.

Capsaicin cream (0.025–0.075%) is an alternative topical option for localised neuropathic or musculoskeletal pain. It works by depleting substance P from sensory nerve endings. It requires consistent application 3–4 times daily for 2–4 weeks before benefit is felt — a point that must be emphasised to prevent premature abandonment. See: Capsaicin Cream for Joint Pain.

OTC codeine-containing products

Co-codamol 8/500 (codeine 8mg + paracetamol 500mg) is available OTC for short-term use (up to three days). However, its role in chronic pain management is problematic:

Dependence risk. Codeine is an opioid. Regular use beyond three days can lead to physical dependence. The MHRA, the Royal Pharmaceutical Society and NICE all highlight the risk of codeine dependence from OTC products.

Medication overuse headache. For patients using codeine-containing products for headache or migraine, use beyond 10 days per month can paradoxically worsen headache frequency — a condition known as medication overuse headache (MOH).

Pharmacy safeguarding role. Pharmacists should be alert to:

• Frequent purchases of codeine-containing products
• Patients visiting multiple pharmacies to obtain codeine
• Requests for specific branded codeine products by name
• Reluctance to discuss the condition being treated

The GPhC expects pharmacists to exercise professional judgement in selling codeine products. Refusing a sale when dependence is suspected is not only permitted but expected. Signpost the patient to their GP or a substance misuse service.

Non-pharmacological options to recommend

Chronic pain management is multimodal. Pharmacy teams should be familiar with evidence-based non-pharmacological approaches to recommend alongside (or instead of) OTC medicines:

• Exercise. NICE recommends exercise as a core treatment for chronic primary pain, osteoarthritis and chronic low back pain. Structured exercise programmes have better evidence than any OTC analgesic for long-term outcomes.
• Physiotherapy. Referral via GP or self-referral (available in many areas without GP involvement).
• TENS (transcutaneous electrical nerve stimulation). Available OTC from pharmacies. Evidence is mixed but it is safe and some patients find it helpful.
• Heat and cold therapy. Simple, cheap and effective for short-term relief of musculoskeletal pain.
• Psychological support. Cognitive behavioural therapy (CBT) for chronic pain has strong evidence. Patients with persistent pain affecting their daily function should be encouraged to discuss this with their GP.

When to refer

Pharmacy teams should refer patients to their GP when:

• OTC analgesia has been used for more than 2 weeks without adequate relief
• The patient is using increasing doses or combining multiple OTC analgesics
• Pain is worsening, waking the patient from sleep, or associated with weight loss, fever or night sweats (red flags for serious pathology)
• There are signs of codeine dependence
• Pain is associated with neurological symptoms (numbness, weakness, altered sensation)
• The patient has not been formally assessed for their pain condition

Pharmacists interested in pain management, palliative care or clinical roles can search current vacancies through PharmSee's job search, which tracks over 1,700 active roles across England.

Sources

• NICE NG193: Chronic pain (primary and secondary) in over 16s — assessment and management.
• NICE NG226: Osteoarthritis in over 16s — diagnosis and management (2022).
• MHRA Drug Safety Update: OTC codeine-containing analgesics — risk of dependence.
• British Pain Society. Chronic pain statistics, 2023.
• Williams CM et al. Efficacy of paracetamol for acute low-back pain (PACE): a randomised controlled trial. The Lancet, 2014.
• PharmSee pharmacy data: pharmsee.co.uk.