Nefopam: The Analgesic Primary Care Forgot

Written by Dr Feroz Mavani

MBChB (Hons), MRCGP, PGDipCert (Digital Health Leadership)

GP Partner & Family Medicine Consultant | NHS Clinical Researcher | Principal Investigator

Peterborough, England, UK

Pain management in general practice often feels constrained between two imperfect poles. On one side sit simple analgesics that are frequently insufficient for moderate or neuropathic pain. On the other sit opioids, effective but burdened with well understood risks that accumulate over time.

Between these extremes lies a small group of medicines that are used inconsistently, understood variably, and rarely discussed in primary care education. Nefopam is one of them.

Although widely used in hospital settings, particularly post operatively, its role in community prescribing remains less clearly defined. Yet its pharmacology and clinical profile raise an interesting question for general practice: are we overlooking a potentially useful non opioid option?

A Different Approach to Analgesia

Nefopam is neither an opioid nor a non steroidal anti inflammatory drug. Instead, it acts centrally through inhibition of serotonin, noradrenaline and dopamine reuptake, alongside modulation of sodium and calcium channels involved in pain transmission.

In practical terms, this produces analgesia without respiratory depression and without the anti inflammatory risks associated with NSAIDs. Unlike opioids, it does not act on opioid receptors and therefore avoids many of the mechanisms underlying dependence and tolerance.

For a GP managing complex multimorbidity, this distinction matters. Many patients with chronic pain also carry contraindications to NSAIDs or are already approaching the limits of acceptable opioid exposure.

Where Nefopam Fits Clinically

Historically, nefopam has been used most commonly for acute postoperative pain, where studies have demonstrated opioid sparing effects when used as part of multimodal analgesia. Reducing total opioid exposure, even modestly, has become an increasingly important goal across healthcare systems.

Translating this into primary care is less straightforward but potentially relevant. Patients discharged after surgery are increasingly started on nefopam in secondary care, leaving GPs to decide whether continuation is appropriate.

In selected patients, nefopam may offer short term analgesic benefit where paracetamol alone is inadequate and NSAIDs or opioids present greater risk. Its lack of respiratory suppression is particularly relevant in older adults or those with respiratory disease, groups in whom opioid escalation often creates clinical unease.

Practical Considerations in General Practice

Despite these advantages, nefopam is not without limitations. Its side effect profile differs from traditional analgesics and can include tachycardia, sweating, nausea, insomnia and anticholinergic type symptoms. These effects are sometimes under recognised outside hospital practice.

There is also limited high quality evidence supporting long term use in chronic pain conditions. Much of the available data relates to acute pain settings, meaning extrapolation into prolonged prescribing should be cautious.

From a primary care perspective, this places nefopam firmly within a considered, time limited strategy rather than as a default ongoing analgesic.

Prescribing decisions therefore benefit from clear treatment goals, early review, and avoidance of silent continuation following hospital initiation. As with many analgesics, the risk is not the drug itself but inertia within prescribing systems.

Why This Matters in Primary Care

General practice increasingly manages patients with persistent pain who fall into therapeutic grey zones. They may not meet thresholds for specialist pain services yet continue to experience functional limitation despite standard treatments.

In this context, expanding awareness of non opioid options is valuable. Nefopam represents an example of multimodal analgesia extending beyond the familiar ladder model that still shapes much prescribing behaviour.

Equally, its existence highlights a broader issue in primary care medicine: some therapies become underused not because they lack value, but because they sit between specialties and never fully belong to one clinical pathway.

A Measured Perspective

Nefopam is unlikely to transform chronic pain management. The evidence base does not support that claim, and careful patient selection remains essential.

However, it may offer a useful adjunct in specific scenarios, particularly short term pain management where opioid avoidance is desirable and NSAIDs are unsuitable. Used thoughtfully, it can contribute to a more nuanced analgesic strategy aligned with current efforts to reduce opioid reliance.

For GPs, the challenge is rarely finding a perfect analgesic. It is assembling safer combinations while maintaining function and minimising harm over time.

Revisiting medicines like nefopam reminds us that innovation in pain management does not always come from entirely new drugs. Sometimes it comes from reassessing existing tools through the lens of modern prescribing priorities.

Reference

Evans, J.M., McMahon, S.B. and colleagues, 1983. The pharmacology of nefopam: a review of its mechanisms and clinical use in pain management. Drugs, 25(3), pp.189–213. Available at: https://link.springer.com/article/10.2165/00003495-198325030-00002 (Accessed: 03 January 2026).