What is the optimal treatment for Chronic Pain Syndrome (CPS)?

From the Guidelines

The best treatment for chronic pain syndrome involves a multimodal approach tailored to each individual, prioritizing non-pharmacological interventions and reserving opioids for cases where other options have failed, as recommended by the most recent guidelines 1.

Key Components of Chronic Pain Management

• Physical therapy to improve function and strength
• Cognitive behavioral therapy to address pain-related thoughts and behaviors
• Medications such as acetaminophen, NSAIDs (e.g., ibuprofen, naproxen), gabapentin, pregabalin, and duloxetine for specific types of pain
• Complementary approaches like acupuncture, massage therapy, and mindfulness meditation for additional relief
• Regular gentle exercise, proper sleep hygiene, and stress management techniques

Medication Considerations

• Acetaminophen (500-1000mg every 6 hours as needed) for mild to moderate pain
• NSAIDs like ibuprofen (400-800mg three times daily with food) or naproxen (500mg twice daily with food) for inflammatory pain
• Gabapentin (starting at 300mg daily, gradually increasing to 300-600mg three times daily) or pregabalin (starting at 75mg twice daily, increasing as needed) for neuropathic pain
• Duloxetine (30-60mg daily) for both pain and associated depression
• Opioids, such as tramadol (50-100mg every 6 hours) or low-dose morphine, should be used cautiously and only when other options have failed, due to their potential for adverse effects and addiction, as highlighted in the CDC clinical practice guideline for prescribing opioids for pain 1.

Non-Pharmacological Interventions

• Cognitive behavioral therapy (CBT) is recommended for chronic pain management, as it promotes patient acceptance of responsibility for change and the development of adaptive behaviors 1.
• Physical and occupational therapy are recommended for chronic pain, focusing on improving function and reducing pain intensity.
• Mindfulness-based therapies, such as mindfulness meditation and yoga, can provide additional relief and improve quality of life.

Recent Guidelines and Recommendations

• The 2021 US Department of Veterans Affairs and US Department of Defense clinical practice guideline for the management of chronic multisymptom illness recommends against the long-term use of opioid medications and suggests offering cognitive-behavioral therapy, mindfulness-based therapies, and physical exercise for patients with chronic pain syndrome 1.
• The CDC clinical practice guideline for prescribing opioids for pain emphasizes the importance of evaluating patients and establishing or confirming the diagnosis, and recommends a nonopioid strategy starting with acetaminophen or NSAIDs for moderate to severe chronic back pain or hip or knee osteoarthritis pain 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 The recommended duloxetine delayed-release capsules dosage is 60 mg once daily in adults with fibromyalgia. Begin treatment at 30 mg once daily for 1 week, to allow patients to adjust to duloxetine delayed-release capsules before increasing to 60 mg once daily. The recommended duloxetine delayed-release capsules dosage is 60 mg once daily in adults with chronic musculoskeletal pain. Begin treatment at 30 mg once daily for one week, to allow patients to adjust to duloxetine delayed-release capsules before increasing to 60 mg once daily

The best treatment for chronic pain syndrome is duloxetine delayed-release capsules at a dosage of 60 mg once daily.

• The treatment should be started at 30 mg once daily for one week to allow patients to adjust to the medication.
• Duloxetine delayed-release capsules have been shown to statistically significantly improve the endpoint mean pain scores from baseline and increase the proportion of patients with at least a 50% reduction in pain score from baseline 2.
• The medication is indicated for the treatment of chronic musculoskeletal pain in adults, including chronic low back pain and chronic pain due to osteoarthritis.
• It is also recommended for the treatment of fibromyalgia in adults at a dosage of 60 mg once daily 2.

From the Research

Treatment Options for Chronic Pain Syndrome

• The treatment of chronic pain syndrome can involve various pharmacological and non-pharmacological approaches, including gabapentin, antidepressants, and other medications 3, 4, 5, 6, 7.
• Gabapentin has been shown to be effective in reducing pain in patients with postherpetic neuralgia and painful diabetic neuropathy, with moderate-quality evidence 3.
• Antidepressants, such as duloxetine and milnacipran, have also been found to be effective in managing chronic pain, particularly in patients with fibromyalgia and neuropathic pain 4.
• The use of strong opioids for chronic neuropathic pain is generally not recommended, as it has been associated with a lower proportion of patients achieving significant pain improvement 6.

Pharmacological Treatments

• Selective serotonin-norepinephrine reuptake inhibitors (SNRIs), such as duloxetine and venlafaxine, are considered primary treatments for neuropathic pain 7.
• Gabapentin and pregabalin are also commonly used to treat neuropathic pain, although pregabalin is considered a second-line treatment in some guidelines due to its lower efficacy and potential for misuse 7.
• Tramadol and combination therapies may be used as adjuncts or second-line treatments for neuropathic pain 7.

Non-Pharmacological Treatments

• Topical lidocaine and transcutaneous electrical nerve stimulation (TENS) may be effective for focal peripheral neuropathic pain 7.
• High-concentration capsaicin patches and botulinum toxin A may also be used for focal peripheral neuropathic pain 7.
• Psychotherapy and other non-pharmacological interventions may be used as adjuncts to pharmacological treatments for chronic pain syndrome 4, 5.