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Considering Medication Options for 3 Main Types of Chronic Pain

Medication Options for Chronic Pain

 

Adapted from Stanos et al. Rethinking chronic pain in a primary care setting. Postgraduate Medicine. 2016;128(5):502-515.

Chronic Pain is a biological, psychological, and social phenomenon.1 For many patients with chronic pain, effective assessment and treatment is multimodal and multidisciplinary, taking into account:

  • ‐ Biological factors (mix of symptoms, type of pain, etc)
  • ‐ Psychological, emotional, and cognitive factors (anxiety, depression, anger, fear of movement, catastrophizing)
  • ‐ Social factors (social and financial circumstances)

Appropriate management of chronic pain may often require pharmacologic interventions, as well as nonpharmacologic interventions, such as psychological therapies, rehabilitative/physical therapies, and complementary/alternative medicine approaches.1,3

Nonpharmacologic intervention can be chosen based on the patient’s profile and treatment availability:

  • ‐ Psychological therapies, such as CBT, relaxation, biofeedback
  • ‐ Rehabilitative/physical therapies, such as stretching, exercise, massage
  • ‐ Other complementary alternative medicine, such as yoga, acupuncture
  • ‐ Patient self-management, such as pacing of activity, brief planned rests

Most patients with chronic pain will need pharmacotherapy, as well.2

Among pharmacologic interventions, prescription opioids are not first-line treatment for noncancer chronic pain.4,5

The graphic above lists recommended medication classes for each of the 3 main types of pain, taken from relevant treatment guideline recommendations. In general, treatment guidelines recommend that prescription opioids be reserved for patients with moderate to severe pain after inadequate response to nonopioid therapy or when other pharmacotherapies are contraindicated.3-8 Opioids should not be used as first-line therapy for chronic noncancer pain, given small to moderate short-term benefits, uncertain long-term benefits, and potential for serious harms.9 Current FDA guidance is to prescribe extended-release and long-acting opioids only for patients with pain severe enough to require daily, around-the-clock, long-term treatment and for whom alternative treatment options are inadequate.10 A summary of the numerous federal and state agency, country, medical society, and clinical guidelines that do not support the use of opioids as first-line treatment for chronic noncancer pain is included below.11-15

It should be emphasized that no patient should receive opioid therapy without a specific, documented diagnosis.16

Adapted from Stanos et al. Rethinking chronic pain in a primary care setting. Postgraduate Medicine. 2016;128(5):502-515.

References

  1. Institute of Medicine of the National Academies. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011. PMID: 22553896
  2. Turk DC, Melzack R. Handbook of Pain Assessment. New York: The Guilford Press: 2011.
  3. Passik SD. Issues in long-term opioid therapy: unmet needs, risks, and solutions. Mayo Clin Proc. 2009;84(7):593-601. PMID: 19567713
  4. Chou R, Fanciullo GJ, Fine PG, et al; American Pain Society–American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130. PMID: 19187889
  5. US Department of Veterans Affairs, US Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. Version 2.0. Washington, DC: US Dept of Veterans Affairs, US Dept of Defense; 2010. http://www.va.gov/PAINMANAGEMENT/docs/CPG_opioidtherapy_summary.pdf. Accessed November 6, 2017.
  6. Washington State Agency Medical Directors’ Group (AMDG). Interagency Guideline on Opioid Dosing for Chronic Noncancer Pain: An Educational Aid to Improve Care and Safety With Opioid Therapy. 2010 Update. Olympia, WA: Washington State Agency Medical Directors Group; 2010. http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf. Accessed November 6, 2017.
  7. Manchikanti L, Abdi S, Atluri S, et al; American Society of Interventional Pain Physicians. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: part 2—guidance. Pain Physician. 2012;15(3 suppl):S67-S116. PMID: 22786449
  8. Utah Department of Health. Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain. Salt Lake City, UT: Utah Dept of Health; 2009. http://www.dopl.utah.gov/licensing/forms/OpioidGuidlines.pdf. Accessed November 6, 2017.
  9. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1-49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.
  10. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107-112. PMID: 15773874
  11. Attal N, Cruccu G, Baron R, et al; European Federation of Neurological Societies. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol. 2010;17(9):1113-1123.
  12. Chou R, Fanciullo GJ, Fine PG, et al; American Pain Society -American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.
  13. Dworkin RH, O'Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain. 2007;132(3):237-251.
  14. Hochberg MC, Altman RD, April KT, et al; American College of Rheumatology. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012;64(4):465-474.
  15. Mirchandani A, Saleeb M, Sinatra R. Acute and chronic mechanisms of pain. In: Vadivelu N, Urman RD, Hines RL, eds. Essentials of Pain Management. New York, NY: Springer Science + Business Media; 2011:45-54.
  16. US Food and Drug Administration. New safety measures announced for extended-release and long-acting opioids: ER/LA opioid analgesic class labeling changes and postmarket requirements [letter to ER/LA opioid application holders]. September 10, 2013. http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM367697.pdf. Accessed November 6, 2017.