2026 BSR Pain Guideline: What Rheumatologists Need to Know Save

Know-it-now

• Treat disease to treat the pain. DMARDs can be our strongest pain intervention; optimize disease control before reaching for analgesics.
• Opioids and gabapentinoids should be demoted but not banned.
• Non-pharmacologic care is under-prescribed - Exercise/physiotherapy access, occupational therapy for ergonomics/orthotics, weight management support, psychological interventions, sleep support and education.
• Quantify pain but talk to the patient. Beyond routine pain-intensity scoring (e.g., 1-10 VAS) at every visit, poorly controlled pain warrants face-to-face review, screening for depression/anxiety/sleep disturbance/disability, and consideration of health beliefs (catastrophizing, self-efficacy)—since up to 40% have neuropathic-like pain and 13–21% have comorbid fibromyalgia.
• Digital tech, complementary therapies, and specific diets remain unproven (they're not disproven, but because the research is poor). This is a "watch this space," not a rejection.

The British Society for Rheumatology has issued its first guideline dedicated solely to pain in inflammatory arthritis (IA)—covering RA, PsA, axial SpA and JIA. UK and BSR officials have noted an increasing number of prescriptions for opioids and gabapentinoids, despite no efficacy evidence, while evidence-supported non-drug options (exercise, weight management) remain underused. Using the GRADE evaluation of the evidence, a multidisciplinary working group has published a lengthy guideline with 23 recommendations addressing assessment, pharmacologic and non-pharmacologic care. Most evidence is low/very-low quality—reflecting the field's evidence gaps more than weak reasoning—but the clinical logic is sound and actionable.

Top Recommendations 

1. Offer DMARDs (unless contraindicated) for active IA to reduce pain and disease activity (1B).
2. Assess pain at every IA visit using VAS/NRS/VRS plus a "is your pain controlled?" question (1C).
3. Face-to-face assessment for poorly controlled pain to identify cause (1C).
4. Ensure access to a rheumatology-expert physiotherapist to support exercise/physical activity (1C).
5. Holistic review for poorly controlled pain: depression, anxiety, sleep, function (1C).
6. Ensure access to occupational therapy for ergonomics, self-management, orthotic assessment (1C).
7. Provide structured education on pain causes and self-management (1B/C).
8. Offer weight-management support/interventions for overweight/obese patients with pain (1C).
9. Signpost to peer/patient-organization support for self-management (1C).
10. Use interpersonal, validating, patient-centered communication during pain assessments (1C).
11. Short-term glucocorticoids as bridging therapy in active RA/polyarticular IA pending DMARD effect (2C).
12. Consider oral NSAIDs at lowest dose/shortest duration, with GI risk mitigation (2C).
13. Offer remote pain assessment (ePROMs) where patients have access/preference, escalating to in-person if uncontrolled (1C).
14. Consider psychological interventions (CBT, mindfulness) for pain; treat comorbid depression/anxiety per national guidance (2C).
15. Consider short-term (1–2 week) non-NSAID analgesics including weak opioids, with harm counseling (2C).
16. Support restoration of healthy sleep patterns in those with pain and disturbed sleep (2C).
17. Evaluate efficacy/side effects of long-term analgesics; support shared-decision tapering (2C).
18. Do not routinely use neuromodulators for IA pain; reserve gabapentinoids for neuropathic pain (2C).
19. Evaluate long-term neuromodulator use similarly and support tapering (2C).
20. Consider evaluating health beliefs (Pain Self-Efficacy Questionnaire, Pain Catastrophizing Scale) in persistent poorly controlled pain (1C).

This guideline formalizes the shift that should already be in play in your rheumatology practice – focus on disease control and multidisciplinary, non-pharmacologic support as first-line pain strategies, and limiting the use of opioids and gabapentinoids. 

The biggest challenge persists as inconsistent access and utilization of physiotherapy, occupational therapy, psychology and weight-management services.

Source: Scott IC, Smith TM, Babatunde O, et al. The 2026 British Society for Rheumatology guideline for pain management in people with inflammatory arthritis. Rheumatology 2026;65(7):keag320.