Diagnosis
Distinguish between Neuropathic pain and Nociceptive pain.
“Treatment options for chronic pain generally fall into six major categories: pharmacologic, physical medicine, behavioral medicine, neuromodulation, interventional, and surgical approaches.” “Currently available treatment modalities on average result in only about a 30 percent decrease in pain. But even a partial response of 30 percent can be clinically significant and improve the patient’s quality of life ”
Neuropathic pain.
1st line: Either antidepressants (TCA or SNRIs) or calcium channel alpha 2-delta ligands (gabapentin and pregabalin), PLUS adjunctive topical therapy when pain is localized.
2nd line: Opioid medications and tramadol.
Nociceptive pain.
Nonnarcotic analgesics and opioid analgesics.
“Acetaminophen is not as effective as NSAIDs for the treatment of knee and hip pain related to osteoarthritis and may cause hepatic damage in patients with the underlying liver disease or at higher doses.
NSAIDs should be avoided in older adults when possible.”
Nonpharmacologic treatment of chronic pain.
Treatment for Chronic Pain By Type of Pain
| Type of Pain | Treatment |
| Neuropathic pain | 1st line: TCA or SNRIs OR gabapentin or pregabalin, PLUS adjunctive topical therapy at the site of the pain. 2nd line: Opioid medications and tramadol. |
| Fibromyalgia | 1st line: SNRIs, TCAs 2nd line: Non-benzodiazepine muscle relaxants, gabapentin/pregabalin. |
| Myofascial pain | Tx same as fibromyalgia |
| Complex Regional Pain Syndrome | Treat like neuropathic pain. |
| Hand OA | 1st line: Topical capsaicin, topical NSAIDs. 2nd line: Oral NSAIDs, tramadol |
| Knee or hip OA | 1st line: APAP 2nd line: NSAIDs 3rd line: Tramadol, opiates, intra-articular steroid injections. |
| Chronic low back pain | 1st line: APAP, NSAIDs 2nd line: TCAs, SSRIs. |
| Localized MSK pain | Topical agents (lidocaine, capsaicin, topical NSAIDs), heat. |
| Irritable Bowel Syndrome | TCAs or SSRIs, antispasmodics. |
| Chronic Pelvic Pain in Women. |
OA = Osteoarthritis.
Gabapentin and pregabalin are calcium channel alpha 2-delta ligands.
Opioid treatment severe forms of acute pain and in cancer pain is recommended. Using opioids to treat chronic noncancer pain is controversial.
NB: Muscle relaxants may also cause CNS depression and should be used cautiously when combined with other CNS depressant medications.
“Acetaminophen is the analgesic of choice for short-term treatment of mild to moderate pain in patients with stage 3–5 chronic kidney disease. Chronic nonterminal pain requires initial treatment with nonopioid analgesics. NSAIDs should be avoided because of the risk of nephrotoxicity.”ABFM
Back pain
- Muscle relaxant
- Lidocaine patch
- Mobic
- Tramadol if needed
Muscle relaxants for chronic pain
Cyclobenzaprine (Flexeril) 10 mg TID (10 to 40 mg/day)
Carisoprodol (Soma) 350 mg three times daily
Baclofen 5 mg once a day, titrated gradually to 5 to 10 mg TID
Methocarbamol (Robaxin) 1500 mg four times daily
World Health Organization (WHO) analgesic ladder
References
http://www.aafp.org/afp/2017/0401/p458.html
http://www.aafp.org/afp/2008/1115/p1155.html
http://www.aafp.org/afp/2016/0301/p380.html
Pocket Primary Care
https://www.uptodate.com/contents/overview-of-the-treatment-of-chronic-non-cancer-pain