Pharmacotherapy of chronic pain: a synthesis of recommendations from systematic reviews.

Author(s): Kroenke K, Krebs EE, Bair MJ

Affiliation(s): Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA. kkroenke@regenstrief.org

Publication date & source: 2009-05, Gen Hosp Psychiatry., 31(3):206-19. Epub 2009 Mar 4.

Publication type: Meta-Analysis; Review

OBJECTIVES: Chronic pain is one of the most prevalent, costly and disabling conditions in both clinical practice and the workplace, yet often remains inadequately treated. Moreover, chronic pain commonly co-occurs with depression, anxiety and somatoform disorders, and adversely affects response of these conditions to psychiatric treatments. This article provides an evidence-based approach to the pharmacotherapy of chronic pain. METHODS: This narrative review is derived largely from meta-analyses and systematic reviews published since 2005. For a few medications, findings from multiple recent trials are synthesized if a systematic review had not yet been published. Classes of medications are first reviewed, followed by an overview of four common pain disorders: neuropathic pain, low back pain, fibromyalgia and osteoarthritis. RESULTS: A stepped care approach based upon existing evidence includes (1) simple analgesics (acetaminophen or nonsteroidal anti-inflammatory drugs); (2) tricyclic antidepressants (if neuropathic, back or fibromyalgia pain) or tramadol; (3) gabapentin, duloxetine or pregabalin if neuropathic pain; (4) cyclobenzaprine, pregabalin, duloxetine, or milnacipran for fibromyalgia; (5) topical analgesics (capsaicin, lidocaine, salicylates) if localized neuropathic or arthritic pain; and (6) opioids. Disease-specific recommendations for neuropathic, low back, fibromyalgia and osteoarthritis pain are reviewed. CONCLUSIONS: A number of medications have proven effective in chronic pain disorders and their use individually or in combination should improve the management of chronic pain.