Pharmacotherapy of chronic pain: a synthesis of recommendations from systematic reviews

Gen Hosp Psychiatry. May-Jun 2009;31(3):206-19. doi: 10.1016/j.genhosppsych.2008.12.006. Epub 2009 Mar 4.

Abstract

Objectives: Chronic pain is one of the most prevalent, costly and disabling conditions in both clinical practice and the workplace, yet often remains inadequately treated. Moreover, chronic pain commonly co-occurs with depression, anxiety and somatoform disorders, and adversely affects response of these conditions to psychiatric treatments. This article provides an evidence-based approach to the pharmacotherapy of chronic pain.

Methods: This narrative review is derived largely from meta-analyses and systematic reviews published since 2005. For a few medications, findings from multiple recent trials are synthesized if a systematic review had not yet been published. Classes of medications are first reviewed, followed by an overview of four common pain disorders: neuropathic pain, low back pain, fibromyalgia and osteoarthritis.

Results: A stepped care approach based upon existing evidence includes (1) simple analgesics (acetaminophen or nonsteroidal anti-inflammatory drugs); (2) tricyclic antidepressants (if neuropathic, back or fibromyalgia pain) or tramadol; (3) gabapentin, duloxetine or pregabalin if neuropathic pain; (4) cyclobenzaprine, pregabalin, duloxetine, or milnacipran for fibromyalgia; (5) topical analgesics (capsaicin, lidocaine, salicylates) if localized neuropathic or arthritic pain; and (6) opioids. Disease-specific recommendations for neuropathic, low back, fibromyalgia and osteoarthritis pain are reviewed.

Conclusions: A number of medications have proven effective in chronic pain disorders and their use individually or in combination should improve the management of chronic pain.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Acetaminophen / therapeutic use*
  • Amines / therapeutic use*
  • Analgesics / therapeutic use*
  • Analgesics, Opioid / therapeutic use*
  • Anti-Inflammatory Agents / therapeutic use*
  • Anti-Inflammatory Agents, Non-Steroidal / therapeutic use*
  • Anxiety Disorders / epidemiology
  • Aspirin / therapeutic use*
  • Chronic Disease
  • Cyclohexanecarboxylic Acids / therapeutic use*
  • Depressive Disorder / epidemiology
  • Gabapentin
  • Guidelines as Topic*
  • Humans
  • Pain / drug therapy*
  • Pain / epidemiology
  • Somatoform Disorders / epidemiology
  • Tramadol / therapeutic use*
  • gamma-Aminobutyric Acid / therapeutic use*

Substances

  • Amines
  • Analgesics
  • Analgesics, Opioid
  • Anti-Inflammatory Agents
  • Anti-Inflammatory Agents, Non-Steroidal
  • Cyclohexanecarboxylic Acids
  • Acetaminophen
  • Tramadol
  • gamma-Aminobutyric Acid
  • Gabapentin
  • Aspirin