What are the recommended approaches for long-term pain management?

Long-Term Pain Management

Core Treatment Framework

Long-term pain management should begin with patient education and supported self-management from the earliest stages, followed by a stepped-care approach that prioritizes non-pharmacological interventions—specifically physical activity/exercise and cognitive behavioral therapy—before considering pharmacological options. 1

Overarching Principles

• Adopt a patient-centered framework within a biopsychosocial perspective, acknowledging pain as a universal experience that requires comprehensive assessment beyond simple symptom control 1
• Establish the patient's functional and valued life goals—specifically what activities they cannot currently perform—rather than focusing solely on pain intensity scores 1
• Early identification of patients at high risk for chronic disability allows more intensive management, better resource allocation, and reduction in long-term disability 1

Initial Assessment Components

The assessment must systematically evaluate:

• Patient needs and priorities: Invite patients to disclose pain's impact on daily functioning, their beliefs about pain causation, perceived control over pain episodes, and treatment expectations 1
• Pain characteristics: Severity, type (nociceptive vs. neuropathic), spread (localized vs. generalized), and quality 1
• Previous treatments: Document all prior interventions and their perceived efficacy to avoid repeating ineffective approaches 1
• Pain-related factors requiring attention: Nature and extent of disability, beliefs and emotions about pain, social influences, sleep problems, and obesity 1
• Underlying pathology: Current inflammation and joint damage as pain sources, and whether these are adequately treated 1

Stepped-Care Treatment Algorithm

Step 1: Education and Self-Management (Universal Access)

• Provide educational materials including brochures or online resources encouraging activity maintenance and sleep hygiene guidelines 1
• Deliver psychoeducation by the health professional during consultations 1
• Offer self-management interventions through online or face-to-face programs 1
• Emphasize early implementation: Patient education and supported self-management should begin immediately, not after other treatments fail 1

Step 2: Specialist Interventions (When Step 1 Insufficient)

Physical Activity and Exercise (First-Line Non-Pharmacological)

Physical activity and exercise interventions demonstrate the most uniformly positive effects on pain across systematic reviews. 1

• For patients able to initiate independently: Provide advice to stay active with specific activity recommendations 1
• For patients unable to initiate without help: Refer to physiotherapist for individually tailored graded physical exercise or strength training 1
• For patients with psychosocial barriers: If fear of movement or catastrophizing cognitions underlie sedentary lifestyle, consider multidisciplinary intervention including cognitive-behavioral therapy 1

Psychological Interventions (First-Line Non-Pharmacological)

Cognitive behavioral therapy shows well-documented effectiveness and cost-effectiveness for chronic non-malignant pain treatment. 1, 2, 3

• CBT targets: Maladaptive pain beliefs, catastrophizing, fear-avoidance behaviors, and promotes adaptive coping strategies 2, 4
• Delivery format: Weekly 90-120 minute group sessions for 6-11 weeks have demonstrated feasibility 1
• Alternative psychological approaches: Acceptance and commitment therapy and mindfulness-based programs have established efficacy 2, 4
• Effects on outcomes: Improves quality of life, physical functioning, and emotional functioning beyond pain reduction alone 2, 4

Specific Modality Recommendations

• Yoga: Strongly recommended specifically for chronic neck/back pain, headache, rheumatoid arthritis, and general musculoskeletal pain 5, 6
• Orthotics and assistive devices: If pain during daily activities impedes functioning, offer splints, braces, insoles, shoes, daily living aids, or ergonomic adaptations through occupational therapy referral 1
• Acupuncture and massage: Physical practices using body techniques show promise as adjunctive interventions 4, 7

Pharmacological Management (When Non-Pharmacological Insufficient)

For neuropathic pain components:

• Gabapentin first-line: Titrate to 2400 mg daily in divided doses, with documented improvements in sleep scores 5, 8
• Alternative agents: Tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors are first-line options 8

For musculoskeletal pain:

• Acetaminophen: Up to 3 grams daily is the safest first-line option, particularly in patients with liver disease, heart problems, or kidney disease 5, 6
• NSAIDs: Use cautiously but avoid completely in patients with cirrhosis (risk of GI bleeding, ascites decompensation, nephrotoxicity) or kidney stones 6

Opioid considerations:

• Reserve chronic opioid use for individuals undergoing active cancer treatment, palliative care, or end-of-life care 2
• If opioids necessary: Always implement multimodal approach to pain management, including mental health support, prior to initiating long-term therapy 9
• Tapering protocol: When discontinuing, reduce by 10-25% of total daily dose every 2-4 weeks to avoid withdrawal symptoms 1, 9

Step 3: Interdisciplinary Pain Management Programs

When single interventions prove insufficient, interdisciplinary programs combining physical therapy, CBT, pain management, and occupational therapy demonstrate superior outcomes. 1, 3

• Program structure: Active treatment phases spanning approximately 1 month, delivered on inpatient or outpatient basis 1
• Evidence quality: Systematic reviews show better outcomes when psychosocial interventions are combined with pharmacological support, though psychological intervention nature varies 1
• Team composition: Include primary care providers, physical/occupational therapists, psychologists, case managers, and pain specialists 5

Monitoring and Reassessment

• Focus assessments on: Achieving functional goals, decreasing pain severity, improving quality of life, and identifying treatment-related adverse events 5
• Use brief tools: The ultra-brief PEG tool (Pain intensity, Enjoyment of life, General activity) enables rapid assessment in busy clinical settings 5
• Regular monitoring: Assess liver function, renal function, and cardiac status when using pharmacological treatments 6
• Therapeutic effect monitoring: Recommendations for ongoing monitoring should be included in the management plan 1

Critical Pitfalls to Avoid

• Do not delay non-pharmacological interventions: The evidence for physical activity/exercise and psychological interventions is strongest; implement these early rather than exhausting pharmacological options first 1, 4
• Do not focus solely on pain intensity: Functional goals, quality of life, and participation in valued activities are equally important outcomes 1
• Do not prescribe opioids without multimodal support: Mental health support and non-pharmacological interventions must be in place before initiating long-term opioid therapy 9, 2
• Do not use NSAIDs in high-risk populations: Absolute contraindication in cirrhosis and kidney stones due to serious complications 6
• Do not implement unproven interventions: This delays evidence-based treatments and wastes resources 5

Special Population Considerations

For patients with comorbid conditions:

• Cirrhosis: Acetaminophen up to 3g daily is safest; avoid NSAIDs completely; if opioids necessary, always prescribe preventive laxative regimen 6
• Kidney disease: Avoid NSAIDs; adjust gabapentin dosing based on renal function 6, 8
• Cardiovascular disease: Avoid NSAIDs due to cardiovascular risks; use acetaminophen as first-line 6

For patients on substance use disorder treatment:

• Methadone maintenance: Split into 6-8 hour doses for continuous pain control; add 5-10% of current dose as afternoon/evening doses 5
• Buprenorphine maintenance: Increase dosage in divided doses initially; add long-acting potent opioid only if maximal buprenorphine doses reached 5