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Chronic Pain Management in Adults

Summary
Basic Information
Treatment
Special Considerations
Follow-Up
Author Affiliations

Jun.22.2024

Chronic Pain Management in Adults

Summary

Key Points

Chronic pain is long-standing pain that persists beyond the usual recovery period (3 months or longer) and often has no clear cause or occurs along with a chronic health condition, such as arthritis or peripheral neuropathy
Systematic classification of chronic pain was developed by the International Association for the Study of Pain, which distinguishes between chronic primary and chronic secondary pain syndromes⁴
- Chronic primary pain is pain in 1 or more anatomic regions that persists or recurs for longer than 3 months and is associated with significant emotional distress or functional disability that cannot be better accounted for by another pain condition
- Chronic secondary pain is pain linked to other diseases as the underlying cause, for which the pain may initially be considered a symptom
Treatment of chronic pain requires a multifaceted approach using intradisciplinary therapies, medications, and interventional procedures
Multidisciplinary rehabilitation employing a biopsychosocial model approach is the most efficacious management for chronic pain and superior to stand-alone treatment¹
Pharmacologic therapy is one component of comprehensive chronic pain management
- Initial treatment options for neuropathic pain include serotonin-norepinephrine reuptake inhibitors (duloxetine, milnacipran), tricyclic antidepressants (nortriptyline), or gabapentin⁹
- Nociceptive pain management approach includes NSAIDs and/or acetaminophen; if these are not effective then serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants can be tried
- Nociplastic pain management options include serotonin-norepinephrine reuptake inhibitors (duloxetine, milnacipran), tricyclic antidepressants (nortriptyline), or gabapentin
Interventional treatments may play a complementary role in chronic pain management
Management of acute flare of chronic pain is generally not an indication for admission
Elderly patients benefit from evaluation using comprehensive pain assessments that consider the multidimensional nature of pain, including physical, psychological, and social aspects
Consider using a "Five A's" approach when managing difficult patients
Monitor safety for all patients on chronic opioid therapy
Iatrogenic complications of medical and interventional pain treatment include:
- Medication adverse effects
- Procedural complications
- Opioid use disorder
- Increased patient passivity and dependence on biomedical treatment
- Deconditioning due to negative belief and fear avoidance
Engage in collaborative discussions with patients to assess their preferences and concerns before considering a referral to a specialist or a condition-specific service

Alarm Signs and Symptoms

Unrelenting pain that is not responsive to usual treatment and that significantly impairs daily activities or quality of life
Worsening pain with history of cancer and unintentional weight loss
Worsening pain with new or worsening neurologic symptoms (eg, weakness, numbness, tingling)
Requests for frequent early refills, unexpected urine drug test results, or use of unprescribed pain medications
Suicidal thoughts or behavior

Basic Information

Terminology

Chronic pain is long-standing pain that persists beyond the usual recovery period (3 months or longer) and often has no clear cause or occurs along with a chronic health condition, such as arthritis or peripheral neuropathy
- It is a multidimensional condition that must be assessed and treated using a combination of biological, psychological, and social approaches
  - Depression, anxiety, and emotional distress contribute strongly to pain intensity, disability, and mortality¹
  - High-impact chronic pain is psychosocial problem with biological aspects (Figure 1)
    - Biological factors involve the actual physical processes that contribute to pain sensations, such as injury, inflammation, nerve damage, or diseases affecting the body's tissues or systems
    - Psychological factors refer to the person's emotions, thoughts, behaviors, and mental health conditions that can influence the experience of pain, including mood (eg, anxiety, depression), beliefs about pain (eg, pain catastrophizing), and coping strategies (eg, avoidance)
    - Social factors encompass the influences of the person's surroundings, relationships, and cultural background on their experience of pain, including the support from family and friends, socioeconomic status, work environment, and cultural beliefs about pain and health
  - There is strong evidence that abuse and trauma are linked with the subsequent development and impact of pain, with posttraumatic stress disorder symptomatology in adulthood making a substantial contribution to those associations¹
Kinesiophobia is an excessive, irrational, and debilitating fear of physical movement triggered by a sense of vulnerability due to painful injury or the fear of reinjury
Central sensitization is a state in which the central nervous system amplifies sensory input across many organ systems, resulting in myriad symptoms²
- Enhanced sensitivity results in perception of pain from nonpainful stimuli (termed allodynia) and greater pain than would be expected from painful stimuli (termed hyperalgesia)
- Chronic pain conditions that may suggest central sensitization include fibromyalgia, chronic nonspecific low back pain, and temporomandibular joint pain. Table 1 has a more extensive list of central sensitization–associated conditions)
- There is a strong association between pain catastrophizing (an exaggerated negative reaction toward actual or anticipated pain experiences) and central sensitization³

Table 1. Central sensitization–associated conditions.

Chronic pain conditions Fibromyalgia Chronic nonspecific low back pain Temporomandibular joint pain Complex regional pain syndrome Chronic whiplash-associated disorder Chronic migraine Chronic tension headache Ehlers-Danlos syndrome Chiari malformation type 1 Atypical facial pain Vulvodynia Chronic fatigue syndrome Myalgic encephalomyelitis Chronic visceral pain conditions Irritable bowel syndrome Chronic pancreatitis Chronic pelvic pain Interstitial cystitis Chronic prostatitis

Background Information

Systematic classification of chronic pain was developed by the International Association for the Study of Pain, which distinguishes between chronic primary and chronic secondary pain syndromes⁴
- Chronic primary pain
  - Pain in 1 or more anatomic regions that persists or recurs for longer than 3 months and is associated with significant emotional distress or functional disability that cannot be better accounted for by another pain condition
    - Examples include widespread pain (eg, fibromyalgia), complex regional pain syndrome, chronic primary headache, chronic orofacial pain (eg, temporomandibular joint disorders), chronic primary visceral pain (eg, irritable bowel syndrome)
  - Considerable overlap of nociceptive, neuropathic, and nociplastic pain exists in patients with chronic pain, with central sensitization being the underlying mechanism
  - Prevalence is as high as 15% of general population⁵
- Chronic secondary pain
  - Linked to other diseases as the underlying cause for which the pain may initially be considered a symptom
  - Chronic pain may continue beyond the successful treatment of the initial cause
Examples include chronic cancer-related pain, chronic postsurgical or posttraumatic pain, and chronic secondary visceral pain
Note that both chronic primary pain and chronic secondary pain can, and often do, coexist
Pain can be further classified by severity using the Graded Chronic Pain Scale Revised⁶ (Figure 2)
- Pain severity is based upon rating of PEG (pain, enjoyment, and general activity) items 3 to 5 in Figure 3
  - Mild chronic pain: low pain intensity and interference (PEG score less than 12)
  - Bothersome chronic pain: moderate to severe pain intensity with lower life-activity interference (PEG score 12 or higher)
  - High-impact chronic pain: sustained pain-related activity limitations (PEG score 12 or higher and pain limiting life or work activities most or every day)

Treatment

Approach to Treatment

Treatment of chronic pain requires a multifaceted approach using intradisciplinary therapies, medications, and interventional procedures
Multidisciplinary rehabilitation employing a biopsychosocial model approach is the most efficacious management for chronic pain and is superior to stand-alone treatment¹
- This model includes a combination of physical, psychological, educational, and/or work-related components that may be delivered by a team of clinicians
Pharmacologic therapy is a part of comprehensive chronic pain management
- Neuropathic (pain caused by nerve damage), nociceptive (pain caused by ongoing inflammation and damage of tissues), and nociplastic pain (pain arising from altered function of pain-related sensory pathways) often overlap and coexist, but predominance of a specific type may help to inform the medication approach⁵
- Neuropathic pain management approach^7,^8,^9,^10,¹¹
  - Initial treatment options include serotonin-norepinephrine reuptake inhibitors (duloxetine or venlafaxine), tricyclic antidepressants (nortriptyline, amitriptyline), or gabapentin⁹
    - Serotonin-norepinephrine reuptake inhibitors and tricyclic antidepressants are more likely to be effective (except in the case of trigeminal neuralgia)
      - Exercise caution when considering tricyclic antidepressants, particularly in older adults (eg, those aged 65 years or older), due to their anticholinergic effects^12,¹³
    - If the initial treatment is not effective or is not tolerated, use a drug in 1 of the remaining 2 classes and consider switching again if that medication is also not effective or not tolerated
  - Consider pregabalin, lidocaine patch, or capsaicin cream as a second line treatment
    - Consider tramadol as a second line if acute rescue therapy is needed
    - Consider high-dose capsaicin patch for severe postherpetic neuralgia or diabetic neuropathic pain
  - Consider a pharmacologic intervention a failure when it is either ineffective after 12 weeks or intolerable
- Nociceptive pain management approach
  - NSAIDs are the first line of treatment of musculoskeletal pain
  - Topical NSAIDs are generally better tolerated than oral NSAIDs
  - Acetaminophen may be used as an adjunct
If NSAIDs and acetaminophen prove to be ineffective, consider treatment for nociplastic pain
- Nociplastic pain management approach
  - Initial treatment options such as serotonin-norepinephrine reuptake inhibitors (duloxetine, venlafaxine) or tricyclic antidepressants (nortriptyline, amitriptyline)
    - Exercise caution when considering tricyclic antidepressants, particularly in older adults (eg, those aged 65 years or older), due to their anticholinergic effects^12,¹³
  - Consider gabapentinoids (gabapentin and pregabalin) if antidepressant is ineffective or intolerable
- Opioid therapy¹⁴
  - Opioid therapy may be considered only if expected benefits for both pain and function are anticipated to outweigh risks to the patient
  - Before starting opioid therapy for chronic pain, treatment goals should be established with patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks
  - Opioid therapy should continue only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety
  - Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy
Interventional treatments may play a complementary role in chronic pain management
Management of acute-on-chronic or chronic pain is generally not an indication for admission

Nondrug and Supportive Care

Multidisciplinary pain rehabilitation programs (eg, interdisciplinary chronic pain rehabilitation program, functional restoration program) provide the best clinical care and may be the most cost-effective long-term treatment option, although initial cost may be a barrier to care^15,¹⁶
Components of a multidisciplinary management plan employing a biopsychosocial model may include:
- Pain neuroscience education
  - Focuses on the neurophysiology and meaning of pain rather than a traditional anatomic and biomedical model to desensitize the neural system
  - 1 of the core points of pain neuroscience education is that "pain is a threat detector and protector, and does not necessarily link to the presence or extent of tissue damage"¹⁷
  - Pain neuroscience education can improve pain, kinesiophobia, and disability whether used alone or in combination with other treatments^18,¹⁹
- Physical therapy/exercise
  - Exercise improves pain sensitivity more than nonexercise interventions²⁰
  - Tailor program to patient-specific limitations, especially for those with fear avoidance, kinesiophobia, or severe deconditioning²¹
  - Advise patients to pace themselves so as to avoid pain flare and discouragement
  - Chronic back pain recommendations
    - All modalities of exercise (except for stretching) reduce pain and functional limitations in people with chronic low back pain^20,²²
    - Some of the most beneficial programs for back pain are those that include:²³
      - Minimum of 1 to 2 sessions per week of Pilates or strength exercises
      - Sessions of less than 60 minutes of core-based, strength, or mind-body exercises
      - Training programs including 3 to 9 weeks of Pilates and core-based exercises
- Mind-body movement therapy
  - Yoga, tai chi, and qigong may improve function, pain, or both^24,²⁵
  - These methods can decrease fear avoidance and kinesiophobia and empower persons to take a proactive role in their own health and wellness²⁵
- Behavioral psychological therapy
  - Validate "pain is absolutely real" regardless of the results of testing and imaging
  - Refer to therapy those persons who:
    - Have buy-in; persons experiencing nociplastic pain or high-impact chronic pain can be highly sensitive to comments implying that their pain is solely psychological (ie, "pain is all in my head")
    - Have bothersome or high-impact chronic pain who are open to learning new coping skills to help manage pain²⁶
  - Treatment modalities include:
    - Cognitive behavior therapy
    - Acceptance and commitment therapy
    - Mindfulness-based stress reduction
  - Is most effective when delivered with an interdisciplinary approach, concomitantly with physical activation and patient education^15,¹⁶
- Pain reprocessing therapy^27,²⁸
  - Pain reprocessing therapy is a psychological treatment aimed at changing a patient's beliefs about the causes and threat value of chronic pain
  - Likely most effective for nociplastic or primary chronic pain, potentially leading to significant and lasting pain relief²⁷
- Lifestyle modifications
  - Unhealthy diet, obesity, sedentary lifestyle, smoking, and stress negatively affect the management of chronic pain²⁹
    - Diet
      - Avoid proinflammatory diet that is positively associated with pain sensitivity (eg, red meat, processed food, sugary foods and drinks, and saturated fat)³⁰
      - Recommend a healthy antiinflammatory diet such as the Mediterranean diet, which consists of nuts, fish, vegetables, unrefined carbohydrates, and olive oil³⁰
    - Activity
      - Sedentary lifestyle is independently associated with back problems
      - Inactivity is associated with muscle weakness and joint degeneration due to reduced synovial fluid production²⁹
      - Normal activities and moderate exercise do not cause permanent tissue damage; remind patients that "hurt is not equal to harm"
      - Pacing is important to minimize pain flare
    - Smoking cessation²⁹
      - Smoking may aggravate the progression of back pain and arthritis by promoting degeneration and degradation of collagen, chondrocytes, and extracellular matrix protein
      - Smoking delays healing and increases complications from fractures and trauma
- Complementary therapies
  - Acupuncture
    - May be used for various chronic pain conditions including low back pain, neck pain, joint pain, fibromyalgia, and headache
    - Can decrease pain intensity immediately after the intervention^24,²⁶
    - Is generally safe; very rare complications include nerve injury and pneumothorax
  - Spinal manipulation
    - Chiropractic therapy may provide short-term relief of musculoskeletal pain²⁴
    - Beneficial when used with exercise³¹
    - Rare but serious complications such as vertebral/carotid artery dissection, stroke, spinal hematoma, or disc herniation have been reported³²
  - Massage
    - May provide short-term benefits for pain and functioning³³
    - No serious adverse effects
  - TENS (transcutaneous electrical nerve stimulation)
    - No solid evidence of benefit for treatment of chronic pain^34,³⁵
    - May provide "in-the-moment" symptomatic relief of pain during and immediately after the treatment³⁴
    - Irrespective of the views of clinicians and guideline recommendations, patients may continue to use TENS transcutaneous electrical nerve stimulation as a safe self-care option because it is readily available without prescription
  - Therapeutic ultrasonography and interferential therapy
    - Not recommended because there is no evidence of benefit^34,³⁶

Drug Therapy

Drug therapy plays a role in comprehensive pain management and is considered a component of therapy (Table 2, Table 3, Table 4)

Table 2. Medications for chronic pain management.
Medication	Indication	Notes
NSAIDs	First line pharmacotherapy for chronic nociceptive pain³⁷	Considerations • Comparable efficacy between NSAIDs³⁸ • Use the lowest effective dose for shortest duration needed • Use either intermittently or in longer cycles rather than long-term use • Use proton pump inhibitors or COX-2-selective NSAIDs if there is a concern for gastrointestinal complication³⁹ Cautions • Increased risk of acute myocardial infarction with all NSAIDs that may occur within 7 days of use³⁹ • Risk of acute kidney damage with all NSAIDs, elevated risk for those with a history of hypertension, heart failure, or diabetes, particularly in the first 30 days after initiation³⁹ • Increased risk of hemorrhagic stroke with diclofenac and meloxicam³⁹
SNRIs First choice • Duloxetine (highest-ranked antidepressant for substantial pain relief, mood, physical function, and sleep)⁴⁰ Second choice • Milnacipran (next most efficacious antidepressant) ⁴⁰	SNRIs have some reported efficacy for nociceptive, neuropathic, and nociplastic pain (fibromyalgia)^5,^12,^40,⁴¹	Considerations • Standard doses (60 mg of duloxetine, 100 mg of milnacipran) are equally efficacious as high dose⁴⁰ • SNRIs usually take 12 weeks to achieve therapeutic effect⁸ • Better tolerated than TCAs¹²
TCAs • Nortriptyline and desipramine may be preferable because of less anticholinergic and sedative adverse effects	TCAs may be helpful for neuropathic pain, nociplastic pain (irritable bowel syndrome, tension headache)⁷	Considerations • Start with low doses at bedtime and with slow titration to higher dose (ie, start low and go slow) • Morning somnolence is common for the first few days of therapy; advise the patient to take earlier in the evening if daytime somnolence persists • Sleep may improve within a few days; effect on pain may take a week or longer Cautions • Common anticholinergic adverse effects (eg, urinary retention, constipation, dry mouth, drowsiness, blurred vision, tachycardia, and cognitive impairment) may occur in more than 60% of patients¹² • Anticholinergic drug use is an independent risk factor for dementia¹³ • High risk of adverse effects for older patients
Carbamazepine/ oxcarbazepine	First line treatment for trigeminal neuralgia^9,⁴²	Considerations • Initial meaningful control in 90% of patients⁴² • If one is not effective, try the other • 200 mg of carbamazepine is equipotent to 300 mg of oxcarbazepine⁴² • If treatment with these medications is not effective, is not tolerated, or is contraindicated, consider seeking expert advice from and a referral to a pain service or specialists Cautions • Adverse effects lead to withdrawal in up to 40% of the patients⁴²
Gabapentinoids	Indicated for neuropathic pain such as postherpetic neuralgia or diabetic peripheral neuropathy Not recommended as a first line for chronic primary pain unless they are offered as a part of trial for complex regional pain syndrome³⁵ Do not prescribe off label for low back pain, sciatica, spinal stenosis, or migraine⁴³	Considerations • Gabapentinoid prescriptions should be considered as a trial for 8 weeks⁴³ • Consider discontinuation if there is no improvement in pain/functioning or the patient experiences adverse events • Avoid abrupt discontinuation that could lead to withdrawal effects such as agitation, dysphoria, and fatigue • Reducing the dose by 50 to 100 mg/day each week for pregabalin and a maximum of 300 mg/day each week for gabapentin is likely to be safe⁴³ Cautions • Avoid gabapentinoids for patients with a known history of substance use disorder. If indispensable, administer with caution by using a strict therapeutic and prescription monitoring^44,⁴⁵ • Pregabalin may have even higher risk of misuse than gabapentin^10,^44,⁴⁵ • Nearly two-thirds of patients experience adverse effects such as dizziness, drowsiness, peripheral edema, and gait disturbance⁴³
Topical lidocaine patch	Second line treatment for peripheral neuropathic pain¹¹	Considerations • Excellent safety profile • Very limited efficacy of short-term relief
Capsaicin high concentration patch (8%)	Second line treatment for severe peripheral neuropathic pain (postherpetic neuralgia, diabetic neuropathy)^10,¹¹	Considerations • Patch should only be applied by a clinician in a well-ventilated area • Should not be applied more frequently than every 3 months
Opioids	Acute-on-chronic pain Chronic pain with moderate to severe intensity	Considerations • For acute-on-chronic pain, use the lowest dose possible and aim toward discontinuing their use as soon as possible • Avoid extended-release or long-acting opioids • Short-term (<6 months): for most acute pain, opioid therapy is not better than NSAIDs and opioid use causes the most harm¹⁴ • Long-term (12 months): opioids are nonsuperior in function and worse in pain intensity to nonopioid medications⁴⁶ • Opioids are less effective for nociplastic pain or central sensitization⁵ Cautions • Adverse effects often outweigh the benefits of long-term opioid treatment: • Respiratory depression, sleep apnea • Drowsiness, decreased concentration and memory, changes in mood • Constipation, abdominal pain, nausea, bowel obstruction • Hormonal changes, sexual dysfunction • Osteopenia • Worsening pain (opioid-induced hyperalgesia) • Concomitant use with a benzodiazepine or gabapentinoid poses a higher risk of misuse, overdose, and premature death and should be avoided whenever possible
Buprenorphine	A preferred choice for patients with chronic pain and opioid dependence, inadequate analgesia, opioid use disorder, pregnancy, or kidney disease⁴⁷	Considerations • Partial µ-opioid receptor agonist allowing potent analgesia with a better safety profile than full agonists • Schedule III opioid with less abuse potential than traditional Schedule II • When switching patients from a full µ-opioid receptor agonist to buprenorphine, convert directly to buprenorphine without a weaning period (see Table 3)⁴⁸ • Microdosing regimen is a novel approach to convert high-dose opioid to buprenorphine that can improve patient comfort by minimizing risk of precipitated withdrawal and fear of opioid taper (see Table 4)^49,⁵⁰
Tramadol	For acute-on-chronic pain, use the lowest dose possible and aim toward discontinuing their use as soon as possible Chronic pain with moderate to severe intensity	Considerations • Tramadol functions as a weak opioid and an SNRI • Like other opioids, it is not the preferred therapy for chronic pain⁵¹ Cautions • Adverse drug reactions include serotonin syndrome and seizures that are secondary to excessive serotonergic activity⁵² • Risk factors for these reactions include concomitant use of serotonergic psychotropic agents (SSRI, TCA, SNRI), history of epilepsy, stroke, renal disease, and traumatic brain injury⁵² • A person's genetics affect tramadol's opioid and serotonergic potency • Poor metabolizers convert less to the active M1 opioid metabolite and are at risk for a hyperserotonergic state, such as serotonin syndrome and seizures, and may report tramadol as ineffective for pain relief and request a stronger opioid⁵³ • Ultra-metabolizers experience the strongest opioid analgesic effects and are more likely to abuse and overdose⁵² • Abrupt cessation of high-dose tramadol increases the risk for both opioid and SNRI withdrawal syndromes⁵²

Table 3. Buprenorphine initiation.
Previous opioid analgesic daily dose (oral morphine equivalent)	Transdermal patch or buccal film
Opioid naive	Initiate 5 mcg/hour transdermally; patches are intended to be worn for 7 days, but doses may be titrated after a minimum of 72 hours; titrate based on analgesic requirement and tolerance; maximum dose is 20 mcg/hour or Initiate 75 mcg buccal buprenorphine once daily, or, if tolerated, twice daily for at least 4 days, then increase dose to 150 mcg every 12 hours. Individual titration to a dose that provides adequate analgesia and minimizes adverse reactions should proceed in increments of 150 mcg every 12 hours, no more frequently than every 4 days; maximum dose is 450 mcg every 12 hours
≤90	Discontinue previous opioid after the last nighttime dose Consider initiating an adrenergic α2 agonist (eg, clonidine, lofexidine) or an immediate-release opioid (eg, current opioid) to reduce the risk of withdrawal, if needed Initiate transdermal buprenorphine at 10 mcg/hour the following morning; replace patch every 7 days; titrate as needed for pain at a minimum interval of every 72 hours; maximum dose is 20 mcg/hour or Initiate 150 mcg of buccal buprenorphine twice daily the following morning; titrate buprenorphine as needed for pain in increments of 150 mcg every 12 hours, no more frequently than every 4 days
>90	Discontinue previous opioid after the last nighttime dose Consider initiating an adrenergic α2 agonist (eg, clonidine, lofexidine) or an immediate-release opioid (eg, current opioid) to reduce the risk of withdrawal Initiate transdermal buprenorphine at 20 mcg/hour the following morning; replace patch every 7 days; maximum dose is 20 mcg/hour or Initiate 300 mcg of buccal buprenorphine twice daily the following morning; titrate buprenorphine as needed for pain in increments of 150 mcg every 12 hours, no more frequently than every 4 days

Table 4. Microdosing initiation.
Day	Buprenorphine	Schedule II opioid
1	0.5 mg (one-quarter of a 2-mg tablet or strip) sublingual daily* or 225 mcg buccal film once daily†	Full dose
2	0.5 mg sublingual twice daily or 225 mcg buccal film twice daily†	Full dose
3	1 mg (one-half of a 2-mg tablet) sublingual twice daily or 450 mcg buccal film twice daily†	Full dose
4	2 mg sublingual twice daily	Full dose
5	4 mg sublingual twice daily	Full dose
6	8 mg every morning, 4 mg every evening	Full dose
7	12 mg	Stop

Management of opioid therapy (Figure 4)
- Initiation of opioids
  - Assess patients for behavioral health conditions, history of traumatic brain injury, and psychological factors (eg, pain catastrophizing) (Figure 5)⁴⁷
    - Consider nonopioid analgesics when patients have a positive result on a catastrophizing screen⁴⁷
  - If opioid therapy trial is considered
    - Discuss limited benefits and substantial risks of adverse outcomes
      - Limited benefits
        Be realistic about expected benefits of opioids, explaining that there is no robust evidence that opioids improve chronic pain that has been present longer than 6 months
        Discuss that the primary goal is improvement in physical, social, and emotional function
      - Risks
        Compared with no opioid use, opioid use is associated with increased risk for opioid use disorder, overdose, all-cause deaths, fractures, falls, and myocardial infarction⁵⁵
        Serious harm is possible even among patients who take the medication as prescribed (comorbidities, drug interaction, declining metabolism with aging, substance use)
        There is no threshold below which there is no risk of harm
    - Assess patients for risks of overdose and opioid use disorder using the following tools:
      - Discussions with patients, family, and caregivers
      - Clinical records
      - Prescription drug monitoring program
      - Urine drug test
      - The Opioid Risk Tool (Figure 6) and The Screener and Opioid Assessment for Patients with Pain (Figure 7) have limited accuracy, necessitating supplementation with other assessments, including discussions with patients and family, clinical records, and prescription drug monitoring program data¹⁴
    - Discuss exit strategy if opioid therapy is unsuccessful
  - Use an informed consent opioid agreement after full discussion with the patient (Figure 8)
    - Use the agreement only in the context of personalized patient counseling and shared decision-making
  - Evaluate patients to assess benefits and risks of opioids within 1 to 4 weeks of starting long-term opioid therapy or of dosage escalation
- Chronic opioid therapy
  - Use buprenorphine for patients receiving daily opioids rather than full agonist opioids⁴⁷
  - Prescribe naloxone to patients at increased risk for overdose, including patients with a history of substance use disorder, sleep disorder, higher dosages of opioids (eg, oral morphine equivalent of 50 or more per day), or patients concurrently taking benzodiazepines or gabapentinoids
  - Safety monitoring
    - Reassess all patients receiving long-term opioid therapy with a suggested interval of every 3 months
    - Use prescription drug monitoring program data and urine drug test to monitor safety; if urine drug test reveals unexpected results:
      - Discuss in a nonjudgmental manner, avoiding use of potentially stigmatizing language (eg, "clean" or "dirty" urine)
      - Use results to improve patient safety and optimize pain management strategy
      - Carefully weigh benefits and risks of reducing or continuing opioid dosage
  - Follow-up assessment
    - Review patient perspectives and goals, and assess pain and function
    - Consider reduction, taper, or discontinuation of opioids in the following scenarios:
      - If there are no meaningful, sustained improvements in pain and function (eg, PEG score) despite opioid therapy
      - Patient experiences overdose or other serious adverse events
- Assuming opioid therapy from other clinicians
  - Carefully weigh the risks and benefits of continuing opioid medications when seeing a new patient who has already been prescribed opioids
    - If benefits outweigh risks, establish treatment goals and review patient responsibilities
    - If benefits do not outweigh risks, discuss patient concerns, optimize other therapies, and work closely with patient to gradually taper to lower dosages and then, if warranted, discontinue opioids
      - If patients disagree on opioid taper, acknowledge this discordance, express empathy, and seek to implement treatment changes in a patient-centered manner while avoiding patient abandonment
- Perioperative management for a patient taking opioids
  - For a patient taking full µ-opioid receptor agonist
    - Consider opioid taper for patients planning elective surgery,^56,⁵⁷ if possible
      - Preoperative use of opioids is associated with:
        Higher postoperative pain score and slower pain resolution⁵⁷
        Increased risk of chronic opioid use^56,⁵⁷
        Increased morbidity and worse outcomes (eg, infection, sepsis, unplanned intubation, cardiac infarction, postoperative transfusion, increased length of stay, reoperation)^56,^57,^58,⁵⁹
    - Implement a multimodal analgesia approach, combining nonopioid analgesics (eg, acetaminophen, NSAIDs, gabapentinoids, ketamine) and regional anesthesia techniques
    - Continue the patient’s baseline opioid regimen to prevent withdrawal symptoms and add short-acting opioids as needed
    - Discharge the patient with the lowest effective dose of opioids for the shortest duration necessary, with a plan for rapid follow-up to reassess pain and medication needs
    - Provide explicit instructions on tapering and discontinuing opioids as postoperative pain diminishes
    - Educate the patient and caregivers about the risks and signs of opioid overdose and the importance of adherence to prescribed regimens
  - For a patient taking buprenorphine^60,⁶¹
    - Continue buprenorphine during the perioperative period without reducing the dose
    - Implement a multimodal analgesia approach, combining nonopioid analgesics (eg, acetaminophen, NSAIDs, gabapentinoids, ketamine) and regional anesthesia techniques
      - If still inadequate, initiate full µ opioid receptor agonist (eg, hydromorphone, morphine, fentanyl)
      - If buprenorphine and multimodal analgesia fail, consider reducing buprenorphine dose
    - Discharge patient on buprenorphine, and, if necessary, limited prescription of full µ opioid receptor agonist with a clear taper plan
- Opioid taper
  - Despite transitory increased pain, evidence suggests improvement of pain and function after an opioid taper⁶²
  - Screen for mental health and opioid use disorders before considering opioid taper^63,⁶⁴
    - Mental health disorders (eg, posttraumatic stress disorder, anxiety, depression)
      - If high suicide risk or patient is actively suicidal, consult with mental health clinician before beginning taper
      - If suicidal, then activate suicide prevention plan
    - Opioid use disorder and other substance use disorders
      - The lifetime prevalence for opioid use disorder among patients receiving long-term opioid therapy is estimated to be about 41%⁶⁴
      - Patients with chronic pain who develop opioid use disorder from opioid analgesic therapy need to have both pain and opioid use disorder addressed
      - Either tapering the opioid analgesic or continuing to prescribe the opioid without providing opioid use disorder treatment may increase the risk of overdose and other adverse events
      - Use a shared decision-making approach to discuss treatment for opioid use disorder, including medication-assisted therapy with either buprenorphine/naloxone or methadone maintenance
      - Medication-assisted therapy can be provided in a variety of treatment settings, including residential/outpatient substance use disorder treatment, regular substance use disorder specialty care clinic, primary care, or general mental health clinic
  - Acknowledge patient’s fear and anxiety regarding opioid taper (Table 5)
    - Educate and collaborate on the tapering plan
    - Consider including patients in decisions such as how quickly or slowly tapering will occur and when pauses in the taper might be warranted^63,⁶⁵
    - Take time to obtain patient buy-in (as long as the current opioid regimen does not put the patient at imminent risk and tapering does not need to occur immediately) ⁶³
  - Risks of taper
    - For patients who have taken opioids long term, opioid taper can be associated with a clinically significant risk of overdose and mental health crisis, particularly if opioids are tapered rapidly^63,⁶⁶
      - Reduce by 5% to 20% every 4 weeks with pauses in taper as needed
      - For patients who have been taking higher doses of long-acting opioid for years, reduce by 2% to 10% every 4 to 8 weeks with pauses in taper as needed^62,⁶⁴
    - Monitor patients for depression and suicidality, and offer psychosocial support for at least 2 years after taper initiation⁶⁶
    - Educate patients regarding risks
      - Advise patients of an increased risk for overdose on abrupt return to a previously prescribed dose because of loss of opioid tolerance
      - Provide opioid overdose education
      - Offer naloxone

Table 5. Opioid taper tools.
Action	Sample language
Listen and address their fears	"Tell me your concerns about reducing opioids"
Discuss the data for patient-centered opioid tapering—the science behind endogenous pain modulation and opioid tapering	"Most patients experience the same or less pain when opioids are tapering the right way—very slowly so that brain and body have time to adjust"
Review the physiology of opioid reduction and how slow tapering will allow for comfortable adaptation. Use adjuvant medications to address discomfort	"Withdrawals are not harmful; they are uncomfortable and mostly preventable. I will help you stay comfortable and will track you closely to make sure you’re doing okay."
Withdrawal symptoms are a sign that the taper is going too fast. Remind them you have a plan to prevent withdrawals, and you will work with them to adjust the taper if any discomfort arises. As much as possible, allow them to feel and be in control	"We create a plan that helps you be in control. You can pause your taper if you need to during a difficult time."
Keep the process very simple, avoid making any other changes during an opioid taper to obviate confounding patient anxiety	–
Maintain a very small dose reduction for the first month	–
Follow-up every 3 weeks for the first few months for close monitoring	–

Treatment Procedures

Interventional treatments may play a complementary role in chronic pain management in conjunction with rehabilitation, pharmacotherapy, and psychological/social/behavioral therapy and support
- Before offering interventional procedures, ensure the patient is an appropriate candidate
  - Characteristics of patients unlikely to derive significant benefit include:^67,^68,^69,^70,^71,⁷²
    - Widespread or multiple pain complaints
    - Chronic pain with long duration
    - Positive Waddle signs (Table 6)
    - Multiple previous medical treatments
    - Multiple comorbid subjective health complaints
    - Multiple failed procedural treatments for pain
    - Unrealistic expectations (excessively high or low)
    - Poor coping
      - Catastrophizing
      - Fear avoidance belief
      - Low self-efficacy
    - High level of depression or anxiety
    - Substance use
    - Inability to work, disability, poor baseline function
    - Litigation pending, receiving worker’s compensation
    - Spousal reinforcement of pain
Interventional noncancer chronic pain management procedures include:
- Epidural steroid injection
  - May provide short-term pain relief for radicular pain⁷³
  - Not effective for chronic axial pain and spinal stenosis⁷⁴
- Facet joint block, medial branch block, or radiofrequency ablation of medial branches
  - Commonly performed in a pain clinic
  - Treats presumed facet joint-mediated pain in the spine
  - Long-term benefits and safety have not been established
  - Possible consequences of repeated/prolonged paraspinal multifidus muscle denervation/atrophy are unknown^75,⁷⁶
- Spinal cord stimulation
  - May provide relief of neuropathic or radicular pain
  - Typically requires trial and implant
  - The rate of complications is as high as 30% to 40%⁷⁷

Table 6. Waddell signs for low back pain.
Category	Clinical findings
Tenderness • Superficial • Nonanatomic	Lumbar skin is tender to touch or light pinch Tenderness in a nonanatomic distribution such as widespread tenderness or tenderness extending into the upper back or pelvis
Sham stimulation • Axial loading • Truncal rotation	Pain reported in the low back while applying downward force on the shoulders or light pressure on the head. Pain reported with passive rotation of the upper body and pelvis in the same plane
Distraction	The patient complains of pain during a straight leg raise during formal testing, such as when supine, but does not on distraction when the examiner extends the knee with the patient in a seated position
Regional disturbances	Weakness, cogwheeling, or the giving way of many muscle groups that are not explained on a neuroanatomic basis Sensory disturbances that cannot be explained by pathology
Overreaction	Disproportionate verbalization or crying, dramatic facial expressions, collapsing, excessively slow or rigid movement, sweating

Admission Criteria

The inpatient acute care setting is not an ideal place for chronic pain management, and episodic flare of chronic pain is not a good indication for admission
Consider admission for further investigation and management of acute pain (acute-on-chronic pain) when red flags are present, such as:
- Unstable or significantly abnormal vital signs
- Pain that is sudden, intense, and unrelenting that significantly impairs daily activities or quality of life
- Acute pain following trauma (such as a fall or accident)
- Pain associated with new or worsening neurologic symptoms (eg, weakness, numbness, tingling), which may indicate nerve compression or other serious issues
- Pain associated with a history of cancer, which may indicate a pathologic fracture or other occult finding

Special Considerations

Older Patients

Use comprehensive pain assessments that consider the multidimensional nature of pain, including physical, psychological, and social aspects⁷⁸
Avoid polypharmacy through regular medication review⁷⁹
Consider deprescribing if there has been no meaningful improvement in function or pain, or when the risk of harm outweighs benefit^79,⁸⁰
- Involve patients and their caregivers in the decision to discontinue medicines when possible
- Patients are more willing to have a medicine deprescribed if they know they can restart it if needed
- Exercise careful deliberation, tapering, and monitoring
Consider cognitive functioning and adjust communication strategies as needed
Evaluate and address fall risk as some pain medications (eg, opioids, tricyclic antidepressants, gabapentinoids, muscle relaxants)^78,⁸¹ and conditions may increase the risk of falls
Prioritize interventions that improve functionality and maintain independence in daily activities
Chronic pain can be isolating, and maintaining social connections is vital for the overall well-being of older adults (eg, those aged 65 years or older)
Provide clear and understandable information about their pain management plan, potential adverse effects, and realistic expectations
Consider involving geriatric specialists or pain management teams experienced in working with older patients to provide comprehensive care

Difficult Patients

Difficult patients are those who raise negative feelings within the clinician, such as frustration, anxiety, guilt, and dislike⁸²
Tools to manage difficult patients include:
- Set appropriate limits with realistic expectations, including the use of clear verbal and written instructions
- Maintain equanimity and do not react to anger
- Be patient, proactive, and nonjudgmental
- Apply empathetic listening and communication skills rather than defensiveness, confrontation, or rejection (Table 7) ⁸³
- Consider using the "Five A's" approach for hostile patients: ⁸²
  - Acknowledge the problem
  - Allow the patient to vent uninterrupted in a private place
    - Listen actively to the patient’s complaints, maintaining eye contact
  - Agree on what the problem is
    - Validate the patient’s feelings
    - Convey kindness and reassurance
  - Affirm what can be done
    - Try to reach some solution
  - Assure follow-through
- Validate concerns, but never be coerced into making decision that could lead to unnecessary risk (eg, potentially harmful tests or treatments)
Notify security if you or staff members feel threatened by a hostile patient and think the patient may become violent
Complete detailed documentation of any hostile encounter but avoid judgmental words

Table 7. Helpful communication techniques.
Goal	Activity	Suggested phrases
Improve listening and understanding	Summarize the patient’s chief concerns Interrupt less	"What I hear from you is that … Did I get that right?"
Improve partnership with patient	Offer regular brief summaries of what you are hearing from the patient Reconcile conflicting views of the diagnosis or the seriousness of the condition Discuss the fact that the relationship is less than ideal; offer ways to improve care	"How do you feel about the care you are receiving from me? It seems to me that we sometimes don’t work together very well."
Improve skills at expressing negative emotions	Decrease blaming statements; increase "I" messages (eg, "I feel …" as opposed to "You make me feel …")	"It’s difficult for me to listen to you when you use that kind of language."
Increase empathy; ensure understanding of patient’s emotional responses to condition and care	Attempt to name the patient’s emotional state; check for accuracy and express concern	"You seem quite upset. Could you help me understand what you are going through right now?"
Negotiate the process of care	Clarify the reason for the patient seeking care Indicate what part the patient must play in caring for his or her health Revise expectations if they are unrealistic	"What’s your understanding of what I am recommending and how does that fit with your ideas about how to solve your problems?" "I wish I (or a medical miracle) could solve this problem for you, but the power to make the important changes is really yours."

Follow-Up

Monitoring

Monitor safety for all patients on chronic opioid therapy with regular follow-up, including the following elements:
- Obtain urine drug tests
- Review prescription drug monitoring program data
- Assess mental health stability (eg, depression, anxiety, posttraumatic stress disorder)
During opioid taper, closely monitor for the following:
- Withdrawal symptoms
- Signs of misuse or overdose
- Mental health stability (eg, worsening depression, anxiety, posttraumatic stress disorder, suicidal ideation or attempt)
For at least 2 years after an opioid taper, monitor with regular visits for:⁶⁶
- Signs of misuse or overdose
- Mental health stability (worsening depression, anxiety, suicidal ideation or attempt)

Complications

Iatrogenic complications of medical and interventional pain treatment may include:^84,^85,^86,⁸⁷
- Overinvestigation and overtreatment
- Heightened reliance on biomedical treatments and a decreased sense of ownership over their health care
- Perpetuation of disabling negative beliefs, including:
  - Hurt (pain) means harm (that pain is a symptom of tissue damage or abnormalities)
  - Biomedical cause of pain (eg, "degenerative changes," "pinched nerves," "slipped disc") will just get worse without medical interventions
  - Fear avoidance and kinesiophobia (ie, belief that pain with movement is a sign of imminent tissue injury and thus should be avoided)
- Opioid pain medication dependence, opioid use disorder
- Medication adverse effects
- Invasive procedure complications

Referral

Engage in collaborative discussions with patients to assess their preferences and concerns before considering a referral to a specialist or a condition-specific service
- For patients with complex high-impact chronic pain or poor response to treatment:
  - Maintain an open dialogue to understand the complexity of a patient's pain, discuss potential specialist involvement, and ensure shared decision-making throughout the referral process
  - Consider referral to a multidisciplinary pain program or clinic using a biopsychosocial approach
- For patients with a significant psychosocial component of chronic pain:
  - Engage in an open dialogue with the patient to discuss psychosocial factors and consider a referral for specialized intervention from a pain psychologist or psychiatrist
- For patients with medication management challenges, especially with substance use concerns:
  - Have a collaborative conversation with the patient, especially when substance use concerns are present; consider optimization of treatment in collaboration with an addiction medicine specialist

Author Affiliations

Isuta Nishio MD, PhD
Associate Professor
Department of Anesthesiology and Pain Medicine
Chronic Pain Service
University of Washington, VA Puget Sound Healthcare System

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