Chronic Pain Management: An Evidence-Based Approach

Basics

Chronic pain lasts longer than 3 months and involves sensory, emotional, and cognitive components. Chronic pain is classified in International Classification of Diseases, 11th revision (ICD-11) as a distinct diagnostic entity.
An epidemic of undertreated pain coexists with an epidemic of prescription drug abuse in the United States.
Racial disparities in pain treatment persist showing implicit bias that impacts analgesic prescribing. Structured decision support and standardized assessments are recommended to minimize this bias.
Management should be multimodal. Nonpharmacologic and nonopioid treatments are recommended as first line for chronic primary pain.

Epidemiology

Incidence

Chronic pain affects ~20% of U.S. adults. 8% experience severe chronic pain that limits major activities.
The economic burden related to chronic pain is estimated to be over $600 billion annually taking into account both direct costs and lost productivity.

Prevalence

In the United States, an estimated 20% (50 million) of adults report some level of chronic pain on cross-sectional household surveys. The prevalence is higher among women and those with lower socioeconomic status (1).

Etiology and Pathophysiology

Chronic pain involves peripheral sensitization, central sensitization, maladaptive neuroplasticity, and dysregulated descending inhibition.
Neuroimaging studies show structural and connectivity changes in the insula, anterior cingulate cortex, amygdala, supporting chronic pain as a CNS disease.
Chronic overlapping pain conditions (e.g., fibromyalgia, temporomandibular pain, and chronic headache) appear to have same neuromodulatory pain mechanisms.

Genetics

Genetic polymorphisms may affect individual’s response to certain opioids (2).

Risk Factors

Traumatic: motor vehicle accidents, repetitive motion injuries, falls
Postsurgical: back surgeries, amputations, thoracotomies
Psychiatric comorbidities include substance abuse, mood disorders, posttraumatic stress disorder (PTSD). Sedentary behavior is an independent and modifiable risk factor for chronic pain.
Disordered sleeping is an independent amplifier of pain severity.
Adverse childhood experiences (ACEs) increase lifetime risk of experiencing chronic pain.

General Prevention

Prevent work-related injuries through ergonomic workplace design.
Encourage regular physical activity.
Varicella vaccine and rapid treatment of shingles to lower risk of postherpetic neuralgia
Tight glycemic control for diabetic patients
Address alcohol and substance use; encourage tobacco cessation.

Commonly Associated Conditions

Any chronic disease and/or its treatment can cause chronic pain.

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