What is the recommended approach to managing a patient with chronic pain syndrome?

Approach to Chronic Pain Syndrome

Implement a structured biopsychosocial assessment followed by multimodal treatment combining physical therapy, cognitive behavioral therapy, and targeted pharmacotherapy based on predominant symptoms, avoiding reliance on opioids as monotherapy. 1

Initial Comprehensive Assessment

Pain History Documentation

Document the following specific elements at the initial visit:

• Temporal characteristics: Exact onset date, duration (must be >3 months for chronic pain diagnosis), daily pattern, and progression over time 1
• Pain descriptors: Quality (sharp, burning, aching, shooting), intensity using numerical rating scale 0-10, precise anatomical distribution with body diagram, and sensory components (numbness, tingling) 1, 2
• Modifying factors: Specific activities that worsen pain (walking, sitting, bending), positions that relieve pain, effects of heat/cold application, impact of stress and weather changes 1, 2
• Motor and autonomic changes: Weakness, muscle atrophy, temperature changes, sweating abnormalities, skin color changes 1
• Treatment history: All previous medications with doses and responses, prior injections or procedures with outcomes, physical therapy trials with duration and effectiveness 1, 2

Medical and Social History

Obtain detailed information on:

• Substance use patterns: Current and past alcohol use, tobacco use, illicit drug history, prescription medication misuse patterns 1
• Occupational impact: Current work status, disability claims, workers' compensation involvement, days missed from work, job modifications required 1
• Surgical history: All prior operations related to pain condition, complications, outcomes 1
• Family dynamics: Support system availability, family members' responses to patient's pain, secondary gain issues 1

Physical Examination Specifics

Perform a targeted examination including:

• Neurologic assessment: Cranial nerve testing, dermatomal sensory examination with light touch and pinprick, motor strength testing of all extremities graded 0-5, deep tendon reflexes, pathologic reflexes (Babinski, Hoffman) 1, 2
• Musculoskeletal evaluation: Visual inspection for asymmetry or atrophy, palpation of tender points, range of motion measurements (active and passive), provocative maneuvers specific to pain location 1, 2
• Functional observation: Observe gait pattern, ability to sit/stand/walk, pain behaviors during examination, consistency of findings 1

Mandatory Psychosocial Evaluation

This is not optional—document the following:

• Psychiatric symptoms: Screen for depression using PHQ-9, anxiety using GAD-7, presence of anger or irritability, sleep disturbance patterns (difficulty falling asleep vs. staying asleep) 1, 2
• Psychiatric diagnoses: Current and past diagnoses including major depression, anxiety disorders, PTSD, personality disorders, history of psychiatric hospitalizations 1
• Coping mechanisms: Active coping strategies (exercise, relaxation) vs. passive coping (catastrophizing, avoidance), social support utilization 1
• Functional impact: Specific activities of daily living affected (dressing, bathing, cooking), social withdrawal, relationship strain, sexual dysfunction 1, 2
• Addiction risk factors: Personal or family history of substance use disorder, aberrant behaviors with medications (early refills, lost prescriptions, dose escalation) 1

Treatment Algorithm

First-Line Multimodal Strategy

Physical/Restorative Therapy (initiate immediately):

• Prescribe structured exercise program including aerobic conditioning, strengthening, and flexibility training for minimum 8-12 weeks 1
• For low back pain specifically, combine physiotherapy with fitness classes showing effectiveness up to 18 months 1
• Set specific functional goals (e.g., walk 30 minutes daily, return to work modified duty) rather than pain reduction alone 1

Psychological Interventions (begin within first month):

• Refer for cognitive behavioral therapy focusing on pain coping skills, activity pacing, and catastrophizing reduction—this has Category A2 evidence for back pain relief lasting up to 2 years 1
• Add biofeedback or relaxation training as adjuncts 1
• Consider group therapy for peer support and shared coping strategies 1

Pharmacotherapy Based on Pain Type:

For neuropathic pain predominance:

• Start pregabalin 75 mg twice daily, titrate to 150-300 mg twice daily based on response 1, 3
• Alternative: duloxetine 30 mg daily, increase to 60 mg daily after one week (also treats comorbid depression) 1, 3
• Consider topical agents (lidocaine patches, capsaicin cream) for localized peripheral neuropathic pain 1

For inflammatory/musculoskeletal pain:

• NSAIDs (naproxen 500 mg twice daily) after assessing GI, renal, and cardiovascular risk 1, 4
• Avoid long-term use beyond 3 months without reassessment 1

For fibromyalgia or widespread pain:

• Amitriptyline 10-25 mg at bedtime, titrate to 50-75 mg for pain, sleep, and fatigue 3
• Alternative: milnacipran for pain and fatigue 3

Opioid Prescribing (Use Cautiously):

• Reserve for severe pain unresponsive to non-opioid strategies 1
• If prescribed, use extended-release formulations for baseline pain, not immediate-release 1
• Establish monitoring plan before first prescription: pill counts, urine drug screens, prescription drug monitoring program checks, functional assessments 1
• Prescribe naloxone when daily morphine equivalent exceeds 50 mg 1
• Any sustained dose increase requires in-person reevaluation to rule out new pathology, tolerance, or misuse 1

Monitoring and Follow-Up Schedule

Initial Phase (First 3 Months):

• Schedule visits every 4-6 weeks 5
• Assess the "Four A's" at each visit: Analgesia (pain intensity change), Activities of daily living (functional improvement), Adverse effects (medication side effects), Aberrant behaviors (signs of misuse) 5
• Use standardized tools: Brief Pain Inventory or 3-item PEG scale for pain impact 5

Maintenance Phase:

• Every 3 months once stable 5
• Reassess treatment goals and adjust strategy if functional improvement plateaus 1, 5

When to Escalate Care

Refer to pain specialist or multidisciplinary pain program when:

• Inadequate response to 3-6 months of multimodal therapy 1, 5
• High-dose opioid requirements (>90 morphine milligram equivalents daily) 1
• Significant psychiatric comorbidity interfering with treatment 1
• Suspected addiction or aberrant drug-related behaviors 1
• Need for interventional procedures (diagnostic blocks, spinal cord stimulation) 1

Telemedicine Adaptations

During circumstances limiting in-person visits (e.g., pandemics, rural locations):

• Conduct comprehensive assessments via video platforms with adequate security (e.g., Microsoft Teams integrated with NHS digital security) 1
• Deliver cognitive behavioral therapy, mindfulness training, and self-management education remotely—systematic reviews show efficacy for internet-based interventions 1
• Perform virtual pill counts and obtain informed consent via video 1
• Allow pharmacy extensions and home delivery of controlled substances with verbal physician authorization where regulations permit 1
• Critical caveat: Any significant sustained opioid dose increase still requires in-person evaluation to exclude new pathology 1

Common Pitfalls to Avoid

• Treating new pain as "just chronic pain": Always reevaluate new pain symptoms to exclude new pathology (infection, malignancy, medication adverse effects) rather than simply increasing existing analgesics 1
• Ignoring psychosocial factors: Untreated depression, anxiety, catastrophizing, and poor coping predict treatment failure regardless of medical interventions 1, 5, 6
• Opioid monotherapy: Opioids alone without physical therapy and psychological treatment lead to poor outcomes and increased risk of misuse 1
• Unrealistic expectations: Communicate that complete pain elimination is rarely achievable; focus on functional restoration and quality of life 1, 5
• Inadequate documentation: Failure to document comprehensive assessment, treatment rationale, and monitoring plan creates medicolegal risk and care fragmentation 1, 2
• Physician enablement: Indiscriminate ordering of tests, procedures, or medications without structured reassessment perpetuates disability 7

Interdisciplinary Team Composition

For complex cases, assemble a team including:

• Pain medicine specialist 1, 5
• Physical therapist 1, 5
• Psychologist or behavioral health specialist 1, 5
• Social worker for vocational and family issues 1
• Palliative care specialist for advanced illness with pain 1

Ensure frequent communication among team members and with patient's support system at health literacy-appropriate level 1