What are the treatment options for chronic pain management?

From the Guidelines

Chronic pain management should prioritize non-pharmacological interventions, with cognitive behavioral therapy (CBT) being a strongly recommended approach, as it promotes patient acceptance of responsibility for change and the development of adaptive behaviors 1. When managing chronic pain, it's essential to consider a multifaceted approach that combines physical therapy, psychological interventions, and medications.

• Non-pharmacological interventions should be the initial approach, including:
  • CBT, which is recommended for chronic pain management (strong, moderate) 1
  • Yoga, which is recommended for the treatment of chronic neck/back pain, headache, rheumatoid arthritis, and general musculoskeletal pain (strong, moderate) 1
  • Physical and occupational therapy, which are recommended for chronic pain (strong, low) 1
• Pharmacological interventions should be considered when non-pharmacological approaches are insufficient, and may include:
  • Acetaminophen or NSAIDs for mild to moderate pain
  • Gabapentinoids, such as gabapentin or pregabalin, for neuropathic pain
  • Duloxetine for both pain and associated depression
  • Low-dose tricyclic antidepressants, like amitriptyline, for severe cases
• It's crucial to note that opioids should be considered only when other options fail, starting with the lowest effective dose and regular monitoring.
• Additionally, hypnosis is recommended for neuropathic pain (strong, low) 1, and clinicians might consider a trial of acupuncture for chronic pain (weak, moderate) 1.
• The values and preferences of this recommendation place a relatively high value on the reduction of symptoms and few undesirable effects, which is essential in chronic pain management 1.

From the FDA Drug Label

A total of 354 patients (234 duloxetine delayed-release capsules, 120 placebo) were enrolled in Study FM-1 and a total of 520 patients (376 duloxetine delayed-release capsules, 144 placebo) were enrolled in Study FM-2 (5% male, 95% female). The patients had a baseline pain score of 6. 5 on an 11-point scale ranging from 0 (no pain) to 10 (worse possible pain). Studies FM-1 and FM-2 compared duloxetine delayed-release capsules 60 mg once daily or 120 mg daily (given in divided doses in Study FM-1 and as a single daily dose in Study FM-2) with placebo Treatment with duloxetine delayed-release capsules 60 mg or 120 mg daily statistically significantly improved the endpoint mean pain scores from baseline and increased the proportion of patients with at least a 50% reduction in pain score from baseline Pain reduction was observed in patients both with and without comorbid MDD. However, the degree of pain reduction may be greater in patients with comorbid MDD. Duloxetine delayed-release capsules are indicated for the treatment of chronic musculoskeletal pain in adults. This has been established in trials in adult patients with chronic low back pain and chronic pain due to osteoarthritis

• Duloxetine is used for chronic pain management in adults, specifically for fibromyalgia and chronic musculoskeletal pain.
• The recommended dosage is 60 mg once daily or 120 mg daily, with 60 mg being the effective dose for most patients.
• Pain reduction was observed in patients with and without comorbid Major Depressive Disorder (MDD), but the degree of pain reduction may be greater in patients with comorbid MDD.
• The drug has been established to be effective in trials for chronic low back pain and chronic pain due to osteoarthritis 2.

From the Research

Chronic Pain Management Approaches

• Nonpharmacologic therapies have become a vital part of managing chronic pain, and can be used as stand-alone therapies or to augment and complement pharmacologic treatments 3
• These nonpharmacologic approaches can be classified as behavioral, cognitive, integrative, and physical therapies, and include techniques such as cognitive behavioral therapy, hypnosis, guided imagery, and mindfulness-based stress reduction 3, 4
• Psychological interventions, such as cognitive behavioral therapy-based interventions and emotion-based therapies, have been shown to be effective in reducing chronic pain 4, 5
• Physical practices, such as exercise, massage, acupuncture, and yoga, can also be used to reduce pain 4

Treatment Modalities

• Effective noninvasive treatment modalities for chronic pain include behavioral therapy for short-term pain relief, cognitive behavioral therapy for reducing long-term pain and disability, and hypnosis as adjunctive therapy 3
• Other treatment modalities, such as guided imagery, diaphragmatic breathing, and muscle relaxation, can be used to manage cancer-related pain 3
• Mindfulness-based stress reduction has been shown to be effective in reducing chronic low back pain 3
• Acupuncture has been shown to be effective in managing multiple pain conditions 3

Comprehensive Treatment Approach

• A comprehensive treatment approach should include explaining the nature of the chronic pain condition, setting appropriate goals, and developing a treatment plan for adherence 3
• Clinicians should become familiar with nonpharmacologic interventions so that they can offer patients flexibility in their pain management approach 3
• A personalized multimodal, interdisciplinary treatment approach, which might include pharmacotherapy, psychotherapy, integrative treatments, and invasive procedures, is typically recommended 6