Pain is the most common reason for which individuals seek
health care. Effective pain management is a core
responsibility of all clinicians, and is a growing priority
among providers, patients and regulators. Despite
increased attention, many patients’ pain remains under-
treated or incorrectly treated.
The prevalence of chronic pain in the US is difficult to estimate, but its impact is profound. Fifty to eighty million Americans suffer daily pain symptoms at a cost of approximately $90 billion annually, and chronic pain is the leading cause of long-term disability in the US. These numbers will only increase as our population ages, amplifying the need for effective, accessible interventions to manage chronic pain and preserve function.
While multidisciplinary subspecialty pain services are increasingly available, primary care providers will continue to manage the majority of patients with chronic pain. This care can be challenging and resource-intensive, and many clinicians feel reluctant or ill-equipped to provide it. This guideline is intended to support clinicians in evaluating and managing patients with chronic pain and, if controlled substance therapy is appropriate for a patient, offer specific guidance and tools for managing these patients in a safe and effective fashion.
The prevalence of chronic pain in the US is difficult to estimate, but its impact is profound. Fifty to eighty million Americans suffer daily pain symptoms at a cost of approximately $90 billion annually, and chronic pain is the leading cause of long-term disability in the US. These numbers will only increase as our population ages, amplifying the need for effective, accessible interventions to manage chronic pain and preserve function.
While multidisciplinary subspecialty pain services are increasingly available, primary care providers will continue to manage the majority of patients with chronic pain. This care can be challenging and resource-intensive, and many clinicians feel reluctant or ill-equipped to provide it. This guideline is intended to support clinicians in evaluating and managing patients with chronic pain and, if controlled substance therapy is appropriate for a patient, offer specific guidance and tools for managing these patients in a safe and effective fashion.
Rationale for Recommendations General Approach
Acute and chronic pain is fundamentally different processes. Acute pain is a protective response to tissue injury and is usually nociceptive, or signaled to the brain via normally functioning afferent neural pathways. Common anti-inflammatory and opioid medications work at different levels in this signal chain to relieve acute pain. Effective acute pain management has been shown to improve both patient satisfaction and treatment outcomes and reduce the risk of developing chronic pain.
Chronic pain is not merely acute pain that does not resolve. In chronic pain patients, abnormal peripheral or central neural function is present. For example, repeated nociceptive stimulation or direct nerve injury can result in neuropathic pain, which is characterized by dysfunctional nerve signaling, increased neural irritability, hyperalgesia (decreased pain threshold), allodynia (heightened pain response to usually non-painful stimuli), and decreased responsiveness to many common pain medications.3, 4 As a result, simply extending acute pain treatments – rest, anti- inflammatory medications, short acting acetaminophen- opioid combinations, etc. – often does not effectively manage chronic pain and, in the case of the use of opioids, may worsen pain for some patients.
Perhaps more importantly, chronic pain also has significant
cognitive, affective and interpersonal components. Patients
with chronic pain are more likely to report depression,
anxiety, poor quality-of-life and financial stress, and are
five times more likely to use health care resources than
patients without chronic pain. Many patients’ chronic pain
is also unlikely to resolve, challenging providers to create
long-term management strategies to maximize function and
limit disability.