INTRODUCTION — Chronic pain is one of the most common reasons that patients seek medical attention. Chronic pain results from combined biologic, psychological, and social factors, and most often requires a multifactorial approach to management. This topic will discuss an approach to the management of chronic non-cancer pain, and an overview of nonpharmacologic therapies. Pharmacologic management of chronic pain, and evaluation of chronic non-cancer pain are discussed separately. (See "Pharmacologic management of chronic non-cancer pain in adults" and "Evaluation of chronic non-cancer pain in adults".)
CREATING A PLAN FOR TREATMENT
General approach — The overarching approach to pain management should reflect the biopsychosocial nature of chronic pain, typically requiring a multidimensional treatment strategy. The 2020 revised definition of pain from the International Association for the Study of Pain (IASP) clarifies the complex nature of pain, and informs the approach to the patient with ongoing pain (table 1) . (See "Evaluation of chronic non-cancer pain in adults", section on 'Chronic pain in context'.)
The appropriate initial therapeutic strategy for chronic pain depends upon an accurate evaluation of the cause of the pain and the type of chronic pain syndrome. In particular, neuropathic pain should be distinguished from nociceptive pain, and pain conditions associated with central sensitization and or nociplastic pain should be recognized (table 2 and table 3). The different types of pain are discussed in detail separately. (See "Evaluation of chronic non-cancer pain in adults", section on 'Definition of pain'.)
●A nociceptive source for pain should be identified and targeted when possible, though the source may not be identifiable, even for pain of high intensity and impact. Treatment of patients with nociceptive pain from structural causes (eg, intervertebral disc, bone-on-bone degenerative joint disease), or inflammatory disorders (eg, rheumatoid arthritis, systemic lupus erythematosus, Crohn disease), or other on-going nociceptive conditions (eg, vaso-occlusive sickle cell disease related tissue infarctions), should whenever possible include targeted treatment directed toward the underlying cause for pain. Examples of such treatment include correction of structural deformity, disease modifying antirheumatic treatments, or maintaining adherence with hydration and hydroxyurea treatment. Targeted disease-specific treatment may reduce or possibly eliminate the need for analgesic drugs (algorithm 1).
●Initial management of the patient with neuropathic pain also involves establishing a diagnosis and pursuing targeted treatment whenever possible. As an example, if nerve function is impaired by compression (eg, carpal tunnel syndrome, trigeminal neuralgia), alleviating the cause of compression, if accomplished early enough, may be all that is needed. (See "Carpal tunnel syndrome: Treatment and prognosis" and "Trigeminal neuralgia", section on 'Surgery for medically refractory TN'.)
●Neuropathic pain and other pain conditions with prominent sensitization can both be managed with similar and often combined treatments, including non-drug (eg, cognitive behavioral therapy, physical activation) and drug treatments (eg, tricyclic antidepressant or serotonin norepinephrine reuptake inhibitor [SNRI], or a gabapentinoid). (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Pharmacologic therapy for neuropathic pain, or nociplastic or centralized pain'.)
Sensitization refers to increased responsiveness of neurons to normal input and/or enhancement/recruitment of a response to typically subthreshold events (table 2). Both peripheral and central sensitization may play a role, though most attention has focused on changes in the spinal cord and brain in sustaining many chronic pain conditions including neuropathic pain, fibromyalgia, persistent postoperative pain, and rheumatologic conditions including osteoarthritis [2-6]. Sensitization plays a prominent role in "nociplastic pain," which is defined as pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain.
In the authors' opinion, chronic pain is best treated in the primary care setting, with collaborative multidisciplinary planning and support . The team ideally includes a pain-informed psychologist or other behavioral health specialist who can focus on psychological aspects of pain perception and coping as well as neuroscience education that informs about psychological mechanisms that are known to modulate pain. Additionally, a pain-informed physical therapist is invaluable for addressing re-conditioning through education and physical exercise focused on enhancing physical function while protecting the individual from pain exacerbation .
Set patient expectations — Patients with chronic pain require ongoing evaluation, education, and reassurance, as well as help in setting reasonable expectations for response. Current chronic pain treatments often result in improvement but not elimination of pain (30 percent reduction on average is typical) . However, even a 30 percent pain reduction can be meaningful in improving quality of life and function, particularly when achieved by incorporating motivational interviewing and pain neuroscience education [10,11].
Empathic and affirmative clinician-patient communications have been demonstrated to improve pain treatment outcomes . The authors recommend spending sufficient time in advance of treatment delivery providing clear explanations for patients to better understand their conditions, share positive and negative expectations and goals of their treatment. The “nocebo response” (the opposite of “placebo”) experience of an adverse response to an otherwise inactive treatment can be predicted by prior lack of response, adverse events, or poor outcomes following prior ineffective treatments . (See "Psychological factors affecting other medical conditions: Management", section on 'Negative expectations'.)
Patient pain neuroscience education — Patient education is a crucial component for effective self-management. Beginning with our initial visit with patients with chronic pain, we explain why pain continues even after tissues have healed, especially when the cause for persistence of pain is not readily apparent. Reducing normal fears (eg, "there must be something wrong," and "hurt means harm") is an important first step toward reactivation and participation in effective techniques for pain self-management. Patients who understand their own chronic disease conditions are more likely to be effective agents in their own treatment outcomes .
Effective explanation of the biopsychosocial mechanisms that contribute to chronic pain can reduce distressing and often overwhelming worries about unexplained symptoms. Many patients bring inaccurately severe explanations for persistent pain. Associated anxiety and catastrophic thinking can worsen the individual experience of pain, and may prompt unnecessary diagnostic procedures and ineffective treatments. Rehabilitation-focused pain clinics often include educational group classes for patients with high disability and distress. These programs address patient questions about why pain "hurts without harm" and include relaxation and reactivation techniques that foster self-management of pain.
The United States National Pain Strategy  and the Institute of Medicine's influential 2010 Relieving Pain in America  both recommend education as a central component to the transformation of pain care. The importance of patient and public education to address the opioid epidemic has also been highlighted in the 2017 report by the Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse of the National Academy of Sciences .
Education is also a key component of psychologically-informed physical therapy (PT), and may improve pain control . In a small randomized trial of patients with chronic low back pain, the combination of pain neurophysiology education with therapeutic exercise resulted in a large improvement in pain intensity at three months, compared with therapeutic exercise alone (mean numeric rating scale 2.7 versus 4.8, scale 0 to 10) . In addition, many of the psychological approaches for chronic pain (eg, cognitive behavioral therapy, mindfulness-based stress reduction [MBSR], biofeedback, relaxation therapy, and psychotherapy) incorporate educational components. (See 'Cognitive-behavioral therapy' below and 'Mind-body therapies' below.)
Patient and family education can be delivered during the course of routine clinical care by a range of clinicians (ie, physician, nurse, psychologist, physical therapist, occupational therapist, social worker, pharmacist). Pain education can also occur in a wide range of settings outside the clinic, including group settings led by health professionals or lay-led ; community-based educational programs ; public advocacy organization sessions; internet resources (eg, US Veterans Administration, U Michigan Fibromyalgia, Understanding Pain in Less Than 5 Minutes, Tame the Beast), and self-help books.
A variety of publicly accessible educational resources and lay-person-led self-management programs are available [21,22]. Selected resources include the following:
Treat sleep disturbance — Sleep disturbance is a common, impactful consequence of chronic pain [23-26]. For patients with insomnia or disrupted sleep, we start with evidence-based nonpharmacologic measures, including improved sleep hygiene and stimulus control. We add cognitive behavioral therapy (CBT) for insomnia, such as the free downloadable application from the United States Department of Veterans Affairs, called CBT-i Coach. For patients who require pharmacotherapy for persistent sleep disturbance, we suggest melatonin, and avoiding benzodiazepines and other sedative hypnotics. If necessary and appropriate, we use the more sedating tricyclics (eg, doxepin, amitriptyline, imipramine) for both antidepressant and analgesic benefits. (See "Evaluation of chronic non-cancer pain in adults", section on 'Pain severity and impact'.)
Management of chronic insomnia is discussed separately. (See "Cognitive behavioral therapy for insomnia in adults" and "Pharmacotherapy for insomnia in adults".)
Start with nonpharmacologic therapy — Effective treatment of pain requires multimodal analgesia , with an emphasis on non-drug modalities (eg, self-management education and training, behavioral health support and physical rehabilitation therapies) (table 3). We generally advise nonpharmacologic therapy initially, favoring active interventions that are movement-based and/or interventions that address psychosocial contributors to pain. An emphasis on active therapy is consistent with a biopsychosocial approach to pain, engages patients in their care, and more directly aims to improve function, not just reduce pain. Passive interventions, such as acupuncture or spinal manipulation, can be effective as adjunctive treatments during symptom flares, and are best in combination with other active interventions (algorithm 1).
For patients who are in process or have transitioned from acute to chronic pain, we always review type and frequency of current and prior non-drug treatments and reconsider whether they need to be modified and/or reinitiated, which is often the case.
NONPHARMACOLOGIC THERAPIES — Successful management of chronic pain requires addressing all of the unpleasant physical and psychologic conditions that result in pain. Nonpharmacologic therapies encompass a wide array of treatments that may be grouped into exercise therapy, the psychoeducational interventions (eg, cognitive-behavioral therapy [CBT], family therapy, psychotherapy, and patient education), mind-body therapies (eg, mindfulness-based stress reduction [MBSR]), and physical interventions (eg, including physical therapy [PT], acupuncture, chiropractic manipulation, massage, and others) (table 3). Combination therapies may be more effective than any single approach for maintaining long-term gains . We emphasize the additive benefit of concomitantly working on movement, normalizing sleep, decreasing distress, optimizing medical management, and focusing on health, and describe this to patients as "piling up the relief." The choice of therapies is individualized based on patient factors, the type of pain, access to care, cost, and patient values and preferences. Examples of studies that have evaluated various noninterventional, nonpharmacologic therapies for chronic pain are as follows:
●In one trial, 342 adults with chronic low back pain were randomly assigned to receive mindfulness based stress reduction (MBSR) therapy, CBT, or usual care for eight weeks . Treatment with MBSR and CBT resulted in greater improvement in back pain and function at 26 weeks than usual care, with similar improvements with MBSR and CBT. Clinically meaningful improvement in pain bothersomeness (defined as >30 percent improvement in a pain bothersomeness score) occurred in 44 percent of patients after MBSR and in 45 percent after CBT, versus 26.6 percent after usual care.
●In a trial including 56 patients with chronic low back pain for ≥6 months who were randomly assigned to therapeutic exercise (ie, motor control, stretching, aerobic exercise) with or without pain neurophysiology education (PNE), patients who received PNE had less pain, improved function, and reduced pain catastrophizing than patients who received only therapeutic exercise .
●A multifaceted collaborative intervention involving 400 patients with chronic musculoskeletal pain (12 weeks or longer) managed in primary care through the United States Veterans Administration system was evaluated in a cluster randomized controlled trial . Patients who were randomly assigned to receive collaborative care (ie, clinician and patient education, a multidisciplinary care program based on individual patient assessment, and recommendations to primary care clinicians) showed small improvements in pain-related disability and pain scales, compared with patients who received usual care. Collaborative care patients were more likely to be prescribed nonopioid adjunctive medications, and when opioids were used they were more likely to be long-acting.
●A single-center study of 163 patients with chronic pain who were entered into an intensive two-week interdisciplinary pain management program reported improved physical, psychological, and social outcomes in half of the participants . Patients with nociceptive pain were four times more likely to improve than those with neuropathic pain, and older patients were more likely to improve across multiple assessed domains. The program included PT, exercise therapy, CBT, and nutrition and pain education.
Physical therapy (PT) — We suggest an individualized physical or occupational therapy program tailored to patient-specific functional limitations for patients with chronic pain, particularly when they are severely deactivated. Improved patient physical function is a key treatment goal for patients with chronic pain. It is important to recognize that PT provided for chronic pain be carefully paced and that fitness activities progress in a graded fashion, so to avoid exacerbating pain, worsening function, and reducing patient willingness to continue. PT includes specific exercise training that addresses both fear avoidance and severe deconditioning commonly seen in patients with chronic pain, and so intrinsically differs from the routine advice given to patients with acute pain (eg, injured athletes, post-op joint replacement surgeries). There is emerging evidence that adding pain neuroscience education to exercise may improve outcomes in many chronic pain conditions [8,32-34]. (See 'Patient pain neuroscience education' above.)
Feeling safe and understanding chronic pain while being physically active encourages patients to increase levels of daily activity. PT demonstrates small-to-moderate effects on pain and disability, some benefit for quality of life, depression, and anxiety . We consider treating patients with chronic pain to be a subspecialty of physical therapy and have found that patients respond best when their therapist has training, interest, and focus on evaluation, motivation, and treatment of chronic pain patients.
Therapeutic exercise — Introducing even very low-level exercise at home with step-wise graduated increases can reactivate severely deconditioned patients and overcome long established fear-avoidance beliefs . Aquatic exercise may be better tolerated by patients with painful osteoarthritis . Therapeutic exercise programs may be available at community centers, or can be pursued at home by accessing internet instructional tai chi videos, yoga classes, Pilates, and low impact fitness programs (eg, Sit and Be Fit).
Evidence in support of therapeutic exercise remains inadequate. A 2017 review of 21 systematic reviews of small randomized trials involving exercise and physical activity for chronic pain concluded that exercise may reduce pain and improve function, with few adverse effects, though quality of evidence was deemed low overall . Nonetheless, we agree with the American College of Physicians 2017 Clinical Practice Guideline, which recommends structured exercise, yoga, tai chi, motor control exercise, progressive relaxation, and electromyography biofeedback, among other first-line chronic pain therapies  (See "Exercise-based therapy for low back pain" and "Psychological, rehabilitative, and integrative therapies for cancer pain", section on 'Therapeutic exercise'.)
Stretching — Stretching programs alone have resulted in improved function and reduced symptoms due to chronic low back pain [40,41]. Stretching intends to restore range of motion (ROM); ROM exercises can progress from passive (in which there is no voluntary muscle contraction and with the application of total external force) to active assisted (in which there is partial contraction and external force). Ultimately, improved musculoskeletal function will require a combination of active strengthening, endurance, balance, as well as flexibility .
Psychological therapy — We consider psychological approaches for patients whose pain impacts mood, sleep, quality of life, or relations with others and are open to incorporating new skills in their approach to pain management. Evidence supports a range of different psychological approaches for managing chronic pain [43,44].
Cognitive-behavioral therapy — Cognitive-behavioral therapy (CBT) is the most commonly recommended and best studied psychological treatment for chronic pain. Behavioral health skills acquisition is most effective when delivered with a multidisciplinary approach, concomitantly with activation (eg, physical therapy, exercise, yoga), patient education, and when indicated, pharmacotherapy or procedural interventions [45,46]. (See 'General approach' above.)
CBT addresses the way that patient thoughts (cognitions) reciprocally interact with their actions (behaviors). CBT targets maladaptive behavioral and cognitive responses to pain, social and environmental factors, and can be distinguished from other psychological therapies for pain (eg, operant-behavioral therapy, mindfulness-based therapy, and acceptance and commitment therapy) and even more so from open-ended psychodynamic or supportive psychological treatments . The importance of assessment of mood and social function in patients with chronic pain cannot be overstated, particularly for psychosocially distressed patients. (See "Overview of psychotherapies", section on 'Cognitive and behavioral therapies' and "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment", section on 'Cognitive behavioral therapy' and "Evaluation of chronic non-cancer pain in adults", section on 'Pain severity and impact'.)
During CBT, patients learn how increased awareness of thoughts can reduce the severity of painful symptoms using a range of specific behavioral strategies used to modify interactions within their environment. CBT deploys a toolbox-of-skills training approach directed towards behavior (relaxation, activity pacing, communication), activation (scheduling of pleasurable events), sleep improvement, and cognitive reappraisal strategies.
●Behavioral skill training involves education related to the behavioral principles, such as conditioning, reinforcement, pain/illness behaviors, and attentional training, and how those principles interact with pain and disability.
●Relaxation and controlled-breathing exercises are especially useful in the skills-acquisition phase because they can be readily learned by almost all patients.
●Typical cognitive training for pain management begins with helping patients understand their own cognitive response system. Specifically, patients can learn to monitor situational factors that trigger their pain/stress and what they actually experience emotionally, behaviorally, and physically when they have pain/stress.
Ideally, CBT is structured, individually goal directed, problem focused, and time limited (often 10 to 20 sessions) . CBT is often delivered as a structured course of one-on-one sessions with a therapist. However, CBT can be effectively administered in a variety of other settings, (eg, within a multidisciplinary pain clinic, in a primary care medical home, or at an independent behavioral health practice site) or with other formats, including in group education via the internet [48,49], or by telephone. In a randomized trial of adult patients with chronic widespread pain, symptom improvement at six months was reported in 8 percent of patients assigned to usual care, 35 percent assigned to CBT via telephone, and 37 percent assigned to a combination of telephone CBT and exercise .
In our practice we find that patients who incorporate CBT skills report less distress, more control over their pain, more realistic expectations, greater treatment satisfaction, and more of a focus on self-directed treatment. Small benefits of CBT have been reported for most chronic pain conditions, though the existing literature is inconclusive. A 2020 meta-analysis of 59 randomized trials of CBT versus no treatment or other forms of behavioral therapy in patients with chronic pain due to a variety of common conditions (eg, fibromyalgia, chronic low back pain, rheumatoid arthritis, or mixed pain states) found small benefits from CBT for pain, disability or distress . Overall quality of evidence was judged to be low to moderate.(See "Evaluation of chronic non-cancer pain in adults", section on 'Pain severity and impact'.)
Mind-body therapies — Mind-body therapy (MBT) describes a broad and heterogeneous range of pain-relieving treatments that incorporate thoughts, emotions, behaviors, movement, and body awareness. MBT includes traditional CBT and mindfulness-based stress reduction (MBSR), and their techniques frequently overlap (eg, relaxation, deep breathing and meditation).
We agree with the American College of Physicians 2017 Clinical Practice Guideline, which recommends structured exercise, yoga, tai chi, motor control exercise, progressive relaxation, and electromyography biofeedback, among other first-line chronic pain therapies .
The evidence supporting a number of these MBTs for chronic pain is of low to moderate quality, but suggests some benefit. In a systematic review of noninvasive nonpharmacologic therapies for various chronic pain disorders, movement, stretching, and breathing based therapy such as yoga were associated with durable moderate improvements in pain and disability, and tai chi improved function and/or pain for at least one month . Hypnosis may have an additive benefit when combined with CBT . A 2020 meta-analysis of 60 studies that evaluated a variety of MBTs in opioid-treated patients with chronic and acute pain found overall moderate improvements in pain and small reductions in opioid dose with the use of MBTs .
Complementary and integrative health therapies — The authors routinely consider and often suggest non-traditional complementary and integrative health (CIH) therapies for chronic pain due to emerging evidence that supports their efficacy and safety. Integrative therapy may be viewed as a care model in which current conventional medical practice approaches are integrated with any of a large number of complementary treatments, including some of the psychological therapies described above. The United States National Center for Complementary and Integrative Health has created an informative patient resource.
Examples of CIH include MBT (eg, mindfulness-based stress reduction, relaxation therapy, imagery, hypnosis, biofeedback, meditation), and massage therapy. Other even less well-studied CIH therapies include biofield therapies (eg, Reiki, therapeutic touch, healing touch) and homeopathy. Most complementary treatments are not associated with known harms. If CIH practitioners are available and the cost is affordable, there are usually no reasons to discourage patients from including such treatments with other conventional therapies. Alternative therapies with potential harm (eg, herbal remedies with potential toxicities or known interactions with other therapy) should be discouraged. (See "Overview of herbal medicine and dietary supplements", section on 'Safety'.)
Dietary interventions — The authors routinely recommend heathy dietary changes at initial visit and reinforce the overall pain-relieving benefits of general health and fitness [53,54], and often direct patients to an online practical guide to diet. We avoid shaming patients and we are careful to not blame chronic pain problems solely on elevated body weight, since this may prevent development of effective therapeutic relationships. We make timely referral to medical dieticians or CIH providers when appropriate.
Integrative therapies for cancer pain are discussed in detail separately; most concepts and principles can be applied to patients with chronic non-cancer pain as well. (See "Psychological, rehabilitative, and integrative therapies for cancer pain", section on 'Integrative therapies'.)
Spinal manipulation — Spinal manipulation may have beneficial short-term benefits in the management of chronic low back pain. The use of spinal manipulation in the treatment of musculoskeletal pain is discussed separately. (See "Spinal manipulation in the treatment of musculoskeletal pain" and "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment", section on 'Spinal manipulation'.)
Acupuncture — We refer chronic pain patients who are open to or interested in acupuncture for a trial of acupuncture therapy. Acupuncture has been a widely used treatment of chronic pain for thousands of years, and continues to be a frequently sought treatment for chronic pain relief.
Although there are significant difficulties in studying acupuncture, randomized trials suggest that acupuncture and sham acupuncture may have similar efficacy, and both are markedly superior to no treatment. We agree with recommendations from the American College of Physicians that acupuncture should be among the first-line nonpharmacologic options for patients with chronic low back pain , and with the UK National Institute of Health Care Excellence (NICE), which suggests acupuncture as an option for chronic headache or migraine that does not respond to pharmacologic treatment . Proposed mechanisms, clinical applications, and the evidence for efficacy are discussed separately. (See "Acupuncture".)
While evidence remains limited, other non-traditional techniques that involve dry needling, intramuscular stimulation, and trigger point injections have reported effectiveness in a number of settings for the treatment of myofascial pain . (See "Management of non-radicular neck pain in adults", section on 'Dry needling and trigger point injections' and "Myofascial pelvic pain syndrome in females: Treatment", section on 'Trigger point'.)
Physical modalities — Physical modalities (eg, transcutaneous nerve stimulation [TENS], transcranial neurostimulation, occipital nerve stimulation) are of uncertain benefit for most types of chronic pain, but may serve as an adjunct to other more active treatments.
Transcutaneous electrical nerve stimulation (TENS) — The role of TENS in the treatment of chronic pain is unclear. We suggest TENS for a subset of patients with localized pain issues as a component of treatment and try to temper patient expectations.
TENS involves application of electrical energy through the skin with a system that allows control of waveform, frequency, and intensity. In the past TENS devices were expensive prescription-only devices in the United States, but now the majority are purchased by the consumer, cost less than $100, and are used without medical supervision. The heterogeneity of devices, application techniques, and patient populations makes it impossible to suggest a specific device for a patient to try.
While numerous small studies support the use of TENS, systemic reviews point out the poor quality of the data and have found inconclusive evidence of efficacy [57-60]. Further research is required to determine the efficacy, parameter specific effects, and cost-effectiveness of TENS.
The use of TENS in specific chronic pain conditions is discussed separately:
Other physical modalities — Transcranial neurostimulation and occipital nerve stimulation are emerging therapies for some types of chronic pain, with limited data regarding efficacy. These therapies are discussed separately. (See "Chronic migraine", section on 'Neurostimulation' and "Treatment of fibromyalgia in adults not responsive to initial therapies", section on 'Brain neuromodulation'.)
There is insufficient evidence of effectiveness to recommend several other popularly endorsed modalities for treatment of chronic pain including ultrasound, low level laser, microwave diathermy, and magnetic pads.
PHARMACOLOGIC THERAPY — For patients with inadequate analgesia despite nonpharmacologic therapies, we add carefully selected multi-targeted pharmacological therapies, based on the type of pain (ie, nociceptive, neuropathic, central sensitization, or a combination). Pain pathways and the effects of the drug therapy on those pathways are shown in a figure (figure 1).
An overview of pharmacologic therapy for chronic pain is discussed separately. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'General principles of drug selection'.)
Pharmacologic therapy for specific chronic pain conditions is discussed in detail in topic reviews of those conditions.
COMPREHENSIVE PAIN REHABILITATION PROGRAM — Where available, referral to a structured pain program may be considered for selected patients with high-impact chronic pain who are unable to achieve important therapeutic goals (eg, return to work or life-role functions) with routine clinical care . Such programs provide coordinated multidimensional treatment focusing on a biopsychosocial model, and may include exercise, coping/relaxation, and medication optimization. These programs may be integrated into a primary care setting, or may involve comprehensive pain programs (CPPs) provided in a specialty setting .
CPPs differ from pain treatment-specific clinics (eg, interventional, or massage). Comprehensive programs typically coordinate care across an interdisciplinary team of clinicians, including rehabilitation trained clinicians, nurses, psychologists, physical and occupational therapists, and vocational counselors . However, these programs vary in other respects, making it difficult to determine the appropriate program for referral. As an example, some programs focus on injured workers while others do not. In addition, improvement in pain and function and cost effectiveness have not been consistently demonstrated with CPPs [62,64-66]. Thus we suggest that referring providers know the program well before placing a referral.
In a 2021 meta-analysis of 57 randomized trials of integrated and comprehensive pain management programs, improvement in pain and/or function were small to moderate compared with usual care, with little long term benefit . Conclusions from this study are limited by lack of information on program and patient specifics and substantial heterogeneity across studies.
INTERVENTIONAL THERAPY FOR CHRONIC PAIN — Interventional approaches typically attempt to target the presumed pain generators or work at a spinal level proximal to the pain (eg, with spinal cord stimulation, intrathecal drug delivery), and may play a complementary role to other strategies. We refer selected patients for interventional therapies, in conjunction with rehabilitation, appropriate pharmacotherapy, and behavioral health support when indicated. The best candidates for interventional management have persistent focal pain of shorter duration, appropriate expectations, and well-managed psychosocial distress. Patients with the opposite characteristics may have poorer response or even worsening of pain.
Interventions for chronic pain range from simple office-based injections into muscles or joints, to advanced neuro-destructive or neuromodulatory procedures used to treat more widespread pain. In primary care settings, injections of steroids and/or local anesthetic into joints, bursae, and muscles (trigger point injections for myofascial pain) are widely available tools that can be effective adjuncts to exercise and other conservative measures.
Among interventional pain procedures performed by pain specialists, the most common are procedures to treat spinal pain. For radicular pain, epidural steroid injections with fluoroscopic guidance  can provide short-term reduction in pain, but their utility in axial pain and lumbar stenosis  is not clearly established. For axial pain, interventional options include diagnostic blocks of the nerves supplying presumed sources of pain (facet joints, sacroiliac joints). If diagnostic blocks result in short-term pain reduction, radiofrequency ablation may provide more sustained relief.
Interventional therapies for chronic pain, including soft tissue and joint injections, epidural steroid injections, nerve blocks, and neuraxial techniques, are discussed separately:
Spinal cord stimulation (SCS) is a minimally invasive, reversible spinal neuromodulation analgesic system. New technologies with novel mechanisms of action have expanded indications and achieved improved outcomes for patients with back pain without leg pain or prior surgery, persistent pain following spinal surgery, neuropathic pain, complex regional pain syndrome (CRPS), intractable angina, and painful peripheral vascular disease, and diabetic neuropathy. These issues are discussed in detail separately. (See "Spinal cord stimulation: Placement and management", section on 'Indications and efficacy' and "Spinal cord stimulation: Placement and management", section on 'Generator characteristics'.)
Surgical procedures for orthopedic chronic pain conditions and back pain are discussed separately. (See "Management of moderate to severe knee osteoarthritis", section on 'Surgery' and "Management of hip osteoarthritis", section on 'Surgery' and "Subacute and chronic low back pain: Surgical treatment".)
MONITORING DURING THERAPY — As with all other chronic diseases, ongoing monitoring of treatments for chronic pain is essential, to deliver effective and safe long-term outcomes. Follow-up evaluation involves monitoring for efficacy and side effects of medications, and reinforcement of the value of non-pharmacologic therapy.
Frequency of scheduled follow-up visits depends upon severity of impact on function, mood, and quality of life; complexity and risk of pain treatments, especially when higher-risk medications are prescribed; number of pain relief-seeking self-referrals to other specialists; and utilization of urgent and emergency care for pain flares. For new patients with chronic pain, and for those patients transitioning from acute to chronic pain, we schedule follow-up visits as often as every two to four weeks in order to establish a therapeutic alliance and maintain patient engagement. We then extend visit intervals to every three to six months or longer based upon measurable progress. We assess improvement with many of the same pain assessment tools as at the initial visit (excepting those historical measures that would not be expected to change, such as the opioid risk tool or posttraumatic stress disorder [PTSD] screener) (table 4). At follow-up visits, we also reinforce pain education, motivate exercise and behavioral compliance with successful treatment, and modify treatment as necessary. (See "Evaluation of chronic non-cancer pain in adults", section on 'Patient evaluation'.)
COVID-19 IMPLICATIONS FOR CHRONIC PAIN — It is too early to predict how COVID-19 pandemic will affect chronic pain in society as a whole or in individuals who recover from infection. However, chronic pain may increase as a result of the pandemic, due to changes to the nervous or musculoskeletal systems, increased stressors to individuals and society, disruptions in health care, or other changes of daily life [70,71]. Persistent symptoms of COVID-19 are discussed separately. (See "COVID-19: Evaluation and management of adults with persistent symptoms following acute illness ("Long COVID")", section on 'Persistent symptoms'.)
Early in the pandemic, care for chronic pain assessment and treatment was deferred for many patients, and for others, changed to virtual rather than in-person visits. Virtual visits offer may increase access to a wider range of multidisciplinary chronic pain care specialties, especially for patients who require frequent follow-up appointments, such as behavioral health visits . However, the full implications of virtual rather than in-person care are not known. Best-practice guidelines have been published for primary care providers, mental health treatment, and procedural pain management [72-74].
Infection control and management of psychiatric illness during the COVID-19 pandemic are discussed separately. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection" and "COVID-19: Psychiatric illness", section on 'General approach'.)
Telemedicine is also discussed in detail separately. (See "Telemedicine for adults".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic pain management".)
SUMMARY AND RECOMMENDATIONS
●Type of pain – The appropriate initial therapy for chronic pain depends upon the cause of the pain and the type of chronic pain syndrome. Neuropathic pain should be distinguished from nociceptive pain, and centralized pain should be recognized (table 2 and table 4). (See 'General approach' above.)
●Patient education – Patient education should include an understanding of how pain can hurt without harm, available treatment options, and reasonable expectations for treatment response. (See 'Set patient expectations' above and 'Patient pain neuroscience education' above.)
●Treat sleep disturbance – For chronic pain patients with insomnia or disrupted sleep, start with nonpharmacologic measures (eg, improved sleep hygiene, cognitive behavioral therapy [CBT]), and only add pharmacologic therapy when necessary, avoiding benzodiazepines. (See 'Treat sleep disturbance' above.)
●Start with non-pharmacologic therapy – The treatment of chronic pain begins with and should always include non-pharmacological approaches ((eg, self-management, behavioral health support and physical therapy). When necessary, we add multi-targeted pharmacologic therapies (algorithm 1 and table 3). (See 'Start with nonpharmacologic therapy' above.)
•We suggest therapeutic exercise for all patients with chronic pain (Grade 2C). We use an individualized physical or occupational therapy program, tailored to patient limitations, with the goal of improving physical function. (See 'Physical therapy (PT)' above.)
•We consider psychological approaches (eg, CBT, mind body therapies) for patients whose pain impacts mood, sleep, quality of life, or relations with others and are open to incorporating new skills in their approach to pain management. (See 'Psychological therapy' above.)
•We routinely consider and often suggest non-traditional complementary and integrative health (CIH) therapies for chronic pain due to emerging evidence that supports their efficacy and safety. (See 'Complementary and integrative health therapies' above.)
•We refer chronic pain patients who are open to or interested in acupuncture for a trial of acupuncture therapy. (See 'Acupuncture' above.)
●Pharmacologic therapy – For patients with inadequate analgesia despite nonpharmacologic therapies, we add carefully selected multi-targeted pharmacological therapies based on the type of pain (ie, nociceptive, neuropathic, central sensitization, nociplastic, or a combination). (See "Pharmacologic management of chronic non-cancer pain in adults".)
●Monitoring – Scheduled follow-up visits promote patient education, therapeutic alliance, treatment engagement, and self-management, and support monitoring and modifying treatments.
Measure pain interference with function, mood, sleep, and quality of life at every pain-related visit, and track these outcomes to determine which treatments to recommend and which treatments to discontinue (table 4). (See 'Monitoring during therapy' above.)
•We refer selected patients for interventional therapies, in conjunction with rehabilitation and appropriate pharmacotherapy. The best candidates for interventional management have persistent focal pain of shorter duration, appropriate expectations, and well-managed psychosocial distress. (See 'Interventional therapy for chronic pain' above.)
•Consider referral to a comprehensive pain program for motivated patients with high-impact chronic pain who are yet unable to achieve important identified functional and quality of life goals despite compliance with routine, less highly structured and lower intensity multidisciplinary pain care. (See 'Comprehensive pain rehabilitation program' above.)