Chronic Pain

Michael Stretanski; Nancy Kopitnik; Anirudh Matha; Till Conermann

Chronic Pain

Author: Michael F. Stretanski Author: Nancy L. Kopitnik Author: Anirudh Matha Editor: Till Conermann Updated: 6/23/2025 12:19:28 AM

Introduction

Nearly 25% of Americans experience chronic pain, which makes it one of the most common conditions encountered in outpatient medical settings.[1] Despite its high prevalence, chronic pain is often undertreated, causing many patients to depend on opioids, which significantly contribute to morbidity and mortality. The economic burden of chronic pain and opioid use disorders in the US exceeds $500 billion annually, surpassing the costs associated with cancer, diabetes, and heart disease. This figure reflects both direct medical expenses and broader societal impacts.[2][3][4]

The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." This definition acknowledges the complex nature of pain, including conditions without apparent tissue injury, such as neuropathic or chronic pain. This definition has gained widespread acceptance among healthcare professionals and researchers and has been adopted by numerous professional, governmental, and nongovernmental organizations, including the World Health Organization (WHO).[5]

In 2018, the IASP slightly revised this definition of pain to: "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." This update more effectively captures pain experiences without apparent tissue damage, such as those observed in neuropathic or chronic pain conditions, and acknowledges the complex, individualized nature of pain.

Chronic pain—defined as pain persisting for more than 3 months—can significantly impair quality of life and daily functioning, often leading to disability. Effective management requires a multimodal approach that combines pharmacological and nonpharmacological therapies, tailored to the individual patient's needs and treatment responses.

Psychiatric comorbidities, especially depression and anxiety, are common yet underrecognized in patients with chronic pain and can significantly worsen pain outcomes. Chronic pain is also associated with an increased risk of suicidal ideation, highlighting the need for comprehensive, integrated care. Given the complexity and far-reaching impact of chronic pain, accurate diagnosis and effective management are essential skills for healthcare professionals. A holistic, patient-centered approach is vital to improving outcomes and enhancing the quality of life for those affected.

Etiology

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Etiology

Most individuals with chronic pain report experiencing multiple types of pain concurrently.[6] For example, a patient with chronic back pain may also have fibromyalgia or other overlapping pain conditions. Additionally, a significant proportion of individuals with chronic pain have comorbid psychiatric disorders. Over 67% are diagnosed with conditions such as major depressive disorder or generalized anxiety disorder, which further complicate clinical management.[7][8]

Classification of Pain

Pain can be classified into several categories, including neuropathic, nociceptive, musculoskeletal, inflammatory, psychogenic, and mechanical types. Below are the examples of each category.

Neuropathic pain

This type of pain is categorized into 2 types, as mentioned below.

Peripheral neuropathic pain. Examples include:
- Postherpetic neuralgia
- Diabetic neuropathy
- Pain following chemoradiation therapy
- Complex regional pain syndrome

Central neuropathic pain. Examples include:
- Pain following a cerebrovascular accident sequella (lacunar infarct)
- Multiple sclerosis
- Spinal cord injuries

Nociceptive pain

This type of pain results from actual tissue injury. Examples include:

Burns
Contusions
Sprains
Postoperative (surgical) pain

Musculoskeletal pain

This type of pain arises from muscles, bones, joints, or related soft tissues. Examples include:

Back pain, including radicular pain following a dermatomal distribution
Myofascial pain

Inflammatory pain

This type of pain is caused by activation of the immune system in response to injury, infection, or autoimmune conditions. Examples include:

Autoimmune disorders
- Rheumatoid arthritis
- Fibromyalgia
- Gout
Infection
Cancer-related pain

Psychogenic pain

This type of pain is primarily influenced by psychological, emotional, and behavioral factors. Examples include:

Tension headaches
Functional abdominal pain
Somatization disorder

Mechanical pain

This type of pain results from structural distortion or compression of tissues. Examples include:

Expanding malignancies
Benign tumors
Advanced ascites
Fractures
Retained hardware pain

Epidemiology

Over 100 million individuals in the United States meet the criteria for chronic pain syndrome, with more than 20 million experiencing severe, debilitating chronic pain.[1] Among those affected, the prevalence of specific pain types varies—chronic regional pain affects approximately 11.1%, chronic back pain 10.1%, leg and foot pain 7.1%, arm and hand pain 4.1%, and headache 3.5%. Additionally, 3.6% of individuals report experiencing widespread chronic pain.[7]

Older adults receive up to 25% fewer pain medications compared to the general population.[9] Chronic pain is also associated with a range of systemic effects, including metabolic disturbances and cognitive disorders.[9][10] Research indicates that the lifetime prevalence of suicide attempts among individuals with chronic pain ranges from 5% to 14%, with approximately 20% reporting suicidal ideation.[11] Among those who died by suicide, 53.6% died from firearm-related injuries, while 16.2% succumbed to opioid overdoses.[12][13][14]

Pathophysiology

Given the diverse pathophysiological origins of pain, no single physiological marker can fully capture all the mechanisms behind its symptoms. Nevertheless, it is widely recognized that, regardless of the type of pain, the resulting impact on patients is often comparable.[15] The complexity of pain perception and its multifaceted nature underscore the importance of a comprehensive, individualized approach to pain management.

History and Physical

A comprehensive medical history is essential for diagnosing and evaluating chronic pain. Clinicians should assess the onset, pain quality (eg, burning, throbbing, and radicular), location, severity, triggers, relieving factors, and whether pain is constant or intermittent. Identifying these characteristics is key to guiding targeted and effective treatment strategies.

Although the numeric pain scale (0–10) is commonly used, it may oversimplify complex pain presentations, particularly when both neuropathic and non-neuropathic components are present. A comprehensive symptom review should also assess for muscle spasms, skin changes, restricted range of motion, stiffness, weakness, sensory deficits, and changes in skin, hair, or nails.[16]

Understanding the functional impact of pain is equally important. Clinicians should assess how pain affects daily activities, relationships, emotional well-being, sleep, and productivity. Asking specific questions about mood, self-care, mobility, and work tolerance offers valuable insight into the patient’s overall condition and quality of life.

The physical examination should support and validate the history, including assessments of strength, flexibility, movement patterns, a neurological exam, and inspection of the skin for signs of chronicity such as excoriation or trophic changes. In older adults, pain is often underreported or described using atypical terms such as “discomfort” or “soreness,” making careful evaluation essential to avoid undertreatment.

Following a comprehensive history, the physical examination should assess strength, range of motion, and flexibility to correlate with reported symptoms and validate pain complaints. Auscultation of the heart and lungs, along with abdominal palpation, offers opportunities to observe movement and detect signs of discomfort or guarded behavior when the patient transitions on and off the examination table.[17] These observations can help differentiate between actual pain and anticipatory fear, both of which may influence diagnosis and management.[17]

A focused neurological examination is essential, with close attention to affected areas for skin changes, temperature differences between extremities, and trophic alterations resulting from prolonged thermal therapies. Signs such as excoriation from chronic scratching or picking, as well as hair loss on the scalp or extremities, may provide valuable diagnostic clues regarding chronicity and underlying pathology.[18]

Older adults commonly experience chronic pain but often face challenges with accurate self-reporting, which can lead to undertreatment.[9][19] They may describe their symptoms as soreness, aching, or discomfort rather than explicitly identifying them as “pain,” complicating both diagnosis and appropriate management.[20][21][22]

Evaluation

Pain assessment in patients with chronic pain is complex and influenced by multiple factors. Some individuals may underreport their symptoms due to concerns about medication reduction, discontinuation of therapy, insurance limitations, or prior authorization challenges. Others may overreport pain due to secondary gain, such as legal claims, disability evaluations, or work avoidance. Ultimately, pain is inherently subjective and cannot be objectively measured.

The Visual Analog Scale (VAS), typically rated from 1 to 10, is the most commonly used pain assessment tool, but is often inadequate. Although it meets documentation requirements, VAS scores can be influenced by factors such as rest, activity, and medication, which limits their reliability. As a self-reported measure, it may lack consistency over time and is insufficiently validated in many chronic pain contexts. Emotional, experiential, and motivational factors further complicate its interpretation, highlighting the limitations of relying solely on numeric scales in chronic pain management. Additionally, secondary motivations may affect pain reporting, further complicating its interpretations.[23]

The VAS often overlaps with other pain assessment tools, including the Graphic Rating Scale (GRS), Numeric Rating Scale (NRS), Simple Descriptive Scale (SDS), Verbal Rating Scale (VRS), the Universal Pain Assessment Tool, and the Wong-Baker FACES Scale. However, in chronic pain management—particularly for long-term planning—greater emphasis should be placed on functional outcomes, quality of life, and tools such as the Functional Independence Measure (FIM), rather than relying solely on isolated numerical VAS scores.

Pain ratings on a scale of 1 to 10 should be interpreted within a broader clinical context, as treatment decisions should not rely solely on self-reported scores. Interventional pain management often adopts a more pragmatic approach, asking patients, “Are you doing well enough for now?" or "Do we need to make a change?” These questions frequently yield more actionable insight than numeric scales alone. Increasingly, the VAS is considered insufficient as a standalone tool for guiding chronic pain care.

Various self-report tools are used to assess pain, with some designed for specific conditions and others for general use. The Brief Pain Inventory (BPI) evaluates patients’ perceptions of pain and its effects on daily functioning and quality of life.[24][25] The Short-Form McGill Pain Questionnaire (SF-MPQ-2) includes pain localization diagrams, medication history, and prior treatment responses.[26] The Neuropathic Pain Scale is particularly useful for assessing and monitoring neuropathic pain.

Generational differences can influence how patients report pain. Younger individuals may rate their pain as “11 out of 10” while appearing outwardly comfortable and engaged, whereas older adults may report low pain scores despite visible signs of physical distress. These contrasts highlight the importance of interpreting pain scores within a broader clinical context, considering factors such as patient behavior, appearance, and overall presentation.

Numeric pain scales remain valuable in specific clinical scenarios. For instance, rating angina before and after nitroglycerin administration can help evaluate treatment effectiveness. Similarly, intra-articular lidocaine injections can assist with pain localization. If a patient reports no relief following a knee injection, the true source of pain may originate elsewhere, such as the lumbar spine or lumbosacral plexus.

Standard blood work and imaging are not routinely recommended for evaluating chronic pain. However, these tests may be appropriate when specific underlying causes are suspected. Laboratory studies can also be ordered on a case-by-case basis, especially to establish baselines before starting medications that may affect hepatic or renal function.

Psychiatric disorders can heighten pain perception and contribute to delays in the diagnosis and treatment of pain conditions.[8][27][28] Among individuals with chronic pain, major depressive disorder and generalized anxiety disorder are the most commonly observed psychiatric comorbidities.

Patients with chronic pain and comorbid psychiatric disorders receive roughly twice as many opioid prescriptions annually compared to those without such conditions.[20] For instance, individuals with depression often experience fatigue, sleep disturbances, decreased appetite, and reduced activity levels—all of which can exacerbate pain symptoms over time. Additionally, chronic pain is associated with an increased risk of both suicidal ideation and suicide.[11][12]

Screening for depression is recommended in patients with chronic pain. The Minnesota Multiphasic Personality Inventory-II (MMPI-2) and the Beck Depression Inventory are the primary tools used to assess depressive symptoms. Of these, the MMPI-2 is more commonly used in the evaluation of patients with chronic pain.[29][30][31][32]

FIM scoring provides an objective assessment of a patient’s functional status over time.[33] Using a 7-point Likert scale (1 = total assistance; 7 = complete independence), FIM scores are based on observed performance via direct observation, interviews, or medical record review.

Although FIM is not a direct measure of pain, it helps guide treatment and management. For instance, a patient with postlaminectomy syndrome who transitions from independent ambulation to using a cane or walker likely reflects worsening pain or neurological decline. Conversely, stable VAS scores after a dural steroid injection may still reflect improvement if the patient no longer requires assistive devices, signaling enhanced functional capacity.

Collateral input from family or caregivers can offer key insights into a patient’s functional progress, especially when self-reports are inconsistent. Patients may downplay their improvements, while observers might note increased activity, such as resuming tasks such as yard work or participating in sports. Emotional factors or fear of treatment changes may contribute to underreporting.

Vital signs, such as an elevated heart rate, blood pressure, respiratory rate, diaphoresis, or guarded movements, can suggest pain or distress. However, in patients with chronic pain, especially those with opioid dependence, these signs may also indicate withdrawal rather than an escalation of pain.

Patients presenting to the emergency department with severe pain may, in some cases, be experiencing opioid withdrawal due to missed appointments, clinic dismissal, nonadherence, or diversion. The Clinical Opiate Withdrawal Scale (COWS) is a valuable tool for assessing the severity of withdrawal and guiding appropriate management.

Individuals who are battered, trafficked, or abused—including men, women, and children—may present with chronic pain as a distress signal or a means to access healthcare and escape dangerous environments. Clinicians should maintain a high index of suspicion and conduct thorough physical examinations to identify signs of abuse, such as cigarette burns, unexplained bruises, defensive injuries, facial trauma, and frequent unexplained emergency department visits.

Patients with chronic pain often seek alternative therapies, sometimes concealing their use from healthcare providers, which can compromise safe and coordinated care. Older adults, particularly those with mild cognitive impairment, are especially vulnerable to misinformation and exploitation. They may believe they are being “cured” and be encouraged to keep treatments secret due to perceived disapproval from conventional medicine. These risks highlight the importance of compassionate, nonjudgmental inquiry and ongoing vigilance.

Regulation of many alternative therapies remains limited. While some herbs and compounds have documented benefits, product labeling is often inaccurate, potentially failing to accurately reflect the actual contents or to disclose harmful substances, such as heavy metals, which raises significant safety concerns.

Treatment / Management

Persistent, debilitating pain despite initial treatment warrants referral to a pain management specialist. Widespread or refractory pain may require multimodal therapy, medication adjustments, or invasive interventions. Some patients may self-medicate with alcohol or illicit substances, highlighting the need for coordinated, multidisciplinary care. Buprenorphine—a mixed agonist-antagonist approved by the US Food and Drug Administration (FDA) in 2002 as Suboxone for opioid dependence and used for pain management since 1966—offers a viable option for managing chronic pain in patients at risk of opioid misuse.

Comprehensive pain management must address both physical pain and coexisting psychiatric conditions. Simultaneous treatment of both has been shown to yield greater reductions in pain severity and associated symptoms.[34][35] Moreover, chronic pain can worsen preexisting depression, underscoring the importance of an integrated approach to improve outcomes for both pain and mood disorders.[36][37](A1)

Patients benefit from a range of treatment options, including pharmacological, adjunctive, nonpharmacological, and interventional therapies. These approaches are tailored to address the individual needs of those living with chronic, severe, or refractory pain.

Pharmacological Therapies

A diverse range of pharmacological options is available for managing chronic pain. Common nonopioid analgesics include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and aspirin. Additional effective medications include tramadol, opioids, and antiepileptic drugs such as gabapentin and pregabalin.

Furthermore, antidepressants, including tricyclic antidepressants (TCAs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), have also demonstrated efficacy in chronic pain management. Other pharmacological options include topical analgesics, muscle relaxants, N-methyl-D-aspartate (NMDA) receptor antagonists, and alpha-2 adrenergic agonists.[35](A1)

Treatment responses vary widely among individuals; however, a stepwise approach is generally preferred to minimize both the duration and dosage of opioid analgesics. Given the absence of a universal treatment strategy for chronic pain, a comprehensive initial evaluation is essential to guide individualized therapy.[38]

Chronic musculoskeletal pain, which is typically nociceptive in nature, is often managed using a stepwise approach that includes nonopioid analgesics, opioids, and nonpharmacological therapies. Acetaminophen and NSAIDs are considered first-line treatments, particularly for conditions such as osteoarthritis and chronic back pain.[39][40][41][42] NSAIDs are relatively contraindicated in patients with cardiovascular disease, renal impairment, gastrointestinal ulcers, or those receiving anticoagulation therapy.[43][44] No single NSAID has demonstrated clear superiority; therefore, trialing different agents is recommended before considering opioids.[45] If pain persists despite appropriate first-line treatments, opioid analgesics may be considered. (A1)

Opioids are considered second-line options for managing severe, persistent pain or cancer-related neuropathic pain.[46] Although the evidence for opioid use in neuropathic pain is mixed, they are frequently used for short- to intermediate-term relief in these cases.[47][48] In chronic musculoskeletal pain, opioids should be prescribed with caution due to associated risks, including hyperalgesia, constipation, dependence, and sedation.[49] Additionally, current evidence suggests that opioids are not more effective than nonopioid analgesics for treating chronic musculoskeletal pain.[50][51](A1)

Opioids may be appropriate when other treatments have proven ineffective or are contraindicated, and when pain significantly impairs the patient’s quality of life. Their use should be preceded by a comprehensive discussion of the potential risks, benefits, and available nonopioid alternatives, as well as ensuring informed patient consent.[50][52][53] (A1)

Patients receiving opioid doses exceeding 100 morphine milligram equivalents (MMEs) per day are at significantly heightened risk for adverse effects, particularly respiratory compromise, with risk increasing at higher dosages. Structured tapering programs are recommended to help reduce opioid use to safer levels.[54][55] Long-acting opioids should be reserved for cases of severe, disabling pain, whereas short-acting opioids are generally preferred in other clinical scenarios.[56][57]

An estimated 78% of patients experience adverse effects from opioid therapy, including constipation and nausea, while approximately 7.5% encounter serious complications such as immunosuppression and respiratory depression.[58] Buprenorphine is recommended for patients with chronic pain who meet criteria for opioid use disorder, particularly those receiving high-dose opioids without sufficient analgesia..[59][60][61](B2)

Pain types require individualized treatment strategies. For instance, chronic musculoskeletal back pain is managed differently from diabetic neuropathy. Neuropathic pain often necessitates a multimodal approach, as fewer than 50% of patients achieve sufficient relief with monotherapy.[62] Adjunctive topical agents, such as lidocaine or capsaicin cream, may also offer added benefit in neuropathic pain management.[63][64][65](A1)

The initial pharmacological treatment of neuropathic pain typically involves gabapentin or pregabalin, both of which are calcium channel alpha-2-delta ligands. These medications are commonly prescribed for conditions such as postherpetic neuralgia, diabetic neuropathy, and mixed neuropathies.[66] While other antiepileptics have limited evidence, lamotrigine is associated with a higher risk of adverse events. Carbamazepine remains a well-established option for trigeminal neuralgia and select chronic neuropathies.[67][68](A1)

Antidepressants, particularly SNRIs and TCAs, are effective for neuropathic pain, central pain syndromes, and chronic musculoskeletal pain. These agents can reduce neuropathic pain intensity by up to 50%, surpassing the average relief of approximately 30% achieved by many other treatments.[69][70][71](A1)

The SNRI duloxetine has shown effectiveness in managing chronic pain conditions such as osteoarthritis and fibromyalgia.[72] In addition to its analgesic benefits, duloxetine offers similar efficacy to other antidepressants in treating comorbid depression.[69][73] Venlafaxine, another SNRI, is also a viable option for treating neuropathic pain.[74] TCAs such as nortriptyline are also effective, although they may require 6 to 8 weeks for full therapeutic effect.[46](A1)

Adjunctive topical agents, such as lidocaine, are effective for managing neuropathic pain and allodynia, particularly in conditions such as postherpetic neuralgia.[75][76] Topical NSAIDs have demonstrated efficacy in treating acute musculoskeletal pain, including strains and sprains. While their role in chronic pain management is more limited, they have shown superior effectiveness to placebo in relieving pain associated with knee osteoarthritis.[77][78] (A1)

Additionally, topical capsaicin cream may be considered for chronic neuropathic or musculoskeletal pain that does not respond to standard treatments.[79] Botulinum toxin has also demonstrated effectiveness in managing postherpetic neuralgia.[80] Medical cannabis is an emerging area of interest in pain management, with some evidence supporting its use for neuropathic pain. However, data on its efficacy for other forms of chronic pain remain limited.[81](A1)

Nonpharmacological Therapies

Various nonpharmacological approaches are used in chronic pain management. These include heat and cold therapy, cognitive behavioral therapy, relaxation techniques, biofeedback, group counseling, ultrasound, acupuncture, aerobic exercise, chiropractic care, physical and occupational therapy, osteopathic manipulation, and transcutaneous electrical nerve stimulation (TENS). Interventional modalities may also be incorporated, such as spinal cord stimulation, epidural steroid injections, radiofrequency ablation, botulinum toxin injections, nerve blocks, trigger point injections, and intrathecal pain pumps.

The efficacy of TENS is variable, with current evidence remaining inconclusive regarding its effectiveness in managing chronic pain.[82] Deep brain stimulation is typically reserved for refractory cases, such as poststroke or facial pain syndromes.[83] Although overall evidence supporting interventional approaches is limited, implantable intrathecal drug delivery systems may be appropriate for patients with persistent, treatment-resistant pain unresponsive to conventional therapies.(A1)

Spinal cord stimulators are a viable treatment option for patients with chronic pain unresponsive to conservative measures. Although most commonly implanted after failed back surgery, other indications include complex regional pain syndrome, painful peripheral vascular disease, intractable angina, painful diabetic neuropathy, and visceral abdominal or perineal pain.[84][85][86][87][88] Research indicates that spinal cord stimulation can result in approximately a 50% reduction in pain compared to continued medical therapy.[89][90][91] These devices are typically implanted at the high lumbar junction, with leads or paddle electrodes optimally positioned near the T8.3 vertebral level—often referred to as the “sweet spot.” Placement may also occur in the cervical spine, and peripheral nerve stimulators may be used to target specific regions such as the greater occipital nerve (GON) or the inguinal canal.(A1)

Individuals with chronic pain often seek alternative or experimental treatments, frequently influenced by online information. Some may purchase unregulated “magic pain pills” or travel abroad—often at considerable personal expense—for unproven therapies. Although medical tourism can provide access to certain benefits, it also poses risks of exploitation and warrants careful evaluation.

Emerging oral and topical alternatives, including herbal remedies and methylene blue, are currently under investigation.[92] However, potential drug-herb and drug-chemical interactions must be carefully considered. Many of these products lack regulatory oversight, and their labels may not accurately represent ingredients or disclose harmful contaminants such as heavy metals.

Differential Diagnosis

Pain is a symptom, not a diagnosis, and effective treatment depends on identifying its underlying cause. In chronic cases, a comprehensive differential diagnosis is essential, particularly in distinguishing peripheral from central neuropathic pain, as each requires a tailored approach. Chronic, widespread pain may stem from complex regional pain syndromes (eg, causalgia and reflex sympathetic dystrophy), opioid-induced allodynia, autoimmune diseases (eg, lupus and psoriatic arthritis), fibromyalgia, central pain syndromes, or psychiatric conditions such as depression, anxiety, bipolar disorder, or schizophrenia.

Localized pain, such as severe knee pain, requires a thorough evaluation to identify the underlying cause. Common etiologies include osteoarthritis, rheumatoid arthritis, lumbar radiculopathy, geniculate nerve pain, and ligament injuries. An accurate diagnosis is essential to guide appropriate treatment, which may include intra-articular injections, disease-modifying antirheumatic drugs (DMARDs), geniculate nerve blocks, radiofrequency ablation, or knee replacement. Other potential causes, such as infection, gout, pseudogout, or meniscal injury, also require targeted, condition-specific interventions.

Chronic pain is often multifactorial and may develop from undertreated acute or subacute pain. Diagnosis should consider 4 primary categories—neuropathic, musculoskeletal, mechanical, and inflammatory. If left unaddressed, neuroplastic changes can cause pain to become self-sustaining, highlighting the critical importance of early intervention.

Clinicians should also evaluate for nonphysiological factors such as malingering, somatization, secondary gain, or abuse. In some cases, chronic pain may serve as a cry for help, particularly in situations involving trafficking or domestic violence. A thorough social and psychological assessment is essential to ensure comprehensive and compassionate care.

Surgical Oncology

In cases of malignancy, surgical oncology plays a central role in initial treatment; however, by the time chronic pain develops, their involvement is often complete. Management then transitions to a multidisciplinary healthcare team, including pain specialists, palliative care providers, and rehabilitation professionals, to address persistent pain related to the disease or its treatment. Optimizing quality of life requires coordinated care that extends beyond the surgical domain.

Treatment Planning

Chronic pain management must address both the underlying cause—often a condition no longer responsive to surgical or curative medical intervention—and the persistent pain itself. The care plan should prioritize minimizing adverse effects, especially drug interactions, as well as anticholinergic and serotonergic effects. When opioids are prescribed, naloxone (Narcan) must also be provided, accompanied by patient education—ideally through training videos available on the manufacturer’s website or platforms such as YouTube.

Interventional Procedures

Pain interventions may be scheduled regularly or used adjunctively—for example, a suprascapular nerve block administered before occupational therapy for adhesive capsulitis to facilitate range of motion (ROM) and stretching (distinct from manipulation under anesthesia). Each procedure requires follow-up planning in accordance with established protocols.

Implantable Technologies

When a spinal cord stimulator is used, long-term care involves periodic reprogramming by a device representative and battery replacement every 7 to 10 years. Subarachnoid pain pumps are more complex, requiring custom, preservative-free medications from a compounding pharmacy. These pumps must typically be refilled every 90 days, regardless of the remaining volume, due to risks of device malfunction, catheter complications, or potential for illicit access.

Toxicity and Adverse Effect Management

All medications carry risks, and polypharmacy is common in chronic pain management. Notably, there are no clinical trials evaluating the safety or efficacy of more than 2 concurrent medications.

For any patient receiving opioid therapy, prescribing naloxone (Narcan) and providing appropriate training are essential. A designated "responsible person" should be informed of the naloxone’s location, view an educational video (available in-office or online), and have the opportunity to ask questions. Documentation of this training should be included in the patient’s medical record.

Self-medication is an additional concern, as patients may supplement prescribed treatments with alcohol, diverted medications, or illicit substances. These behaviors must be addressed during care planning. Interventions can range from trigger point injections to subarachnoid pain pumps, each carrying its own risk profile. Potential toxicities associated with local anesthetics, corticosteroids, platelet-rich plasma (PRP), and contrast agents should be carefully considered.

Interventional procedures such as epidural steroid injections, radiofrequency ablations, and spinal cord stimulator placements can carry significant risks. These interventions should be performed only in settings equipped to manage emergencies, including access to “lipid rescue” protocols when using bupivacaine or other high-risk local anesthetics. Please see StatPearls' companion resource, "Lipid Emulsion Therapy," for more information on this treatment for local anesthetic systemic toxicity.

Prognosis

Current treatments for chronic pain generally result in about a 30% reduction in pain, which can significantly improve function and quality of life.[38][93] However, the long-term prognosis often includes persistent reductions in overall function and quality of life. Outcomes improve when comorbid psychiatric conditions are treated concurrently. Chronic pain is associated with increased morbidity and mortality, a higher incidence of chronic disease and obesity, and a significantly elevated risk of suicide compared to the general population.

Spinal cord stimulation provides inadequate pain relief in approximately 50% of patients, with tolerance developing in 20% to 40%, and its effectiveness often declines over time.[94] Similarly, patients using opioids for chronic pain frequently develop tolerance, and higher MMEs are associated with increased morbidity and mortality.

Prevention is key in chronic pain management. Proper treatment of acute and subacute pain can reduce the risk of progression to chronic pain, helping to minimize disability and preserve quality of life.

Complications

Chronic pain significantly impairs quality of life, productivity, and social functioning, often resulting in disability and lost income. The pain can exacerbate existing chronic diseases and is closely linked to psychiatric conditions such as depression, anxiety, and substance use disorders. Individuals with chronic pain also face a heightened risk of suicidal ideation and suicide. The associated sedentary lifestyle further contributes to both physical and psychological complications, with extensive literature documenting the adverse effects of prolonged immobility.[95]

Many medications used to manage chronic pain carry significant risks. Acetaminophen, often used alone or in combination with opioids, can cause hepatotoxicity, particularly at doses exceeding 4 grams per day, and is the leading cause of acute liver failure in the United States.[96][97] Furthermore, hepatotoxicity can occur at therapeutic doses for patients diagnosed with chronic liver disease.[98]

Gabapentin and pregabalin, commonly used as adjuncts in pain management, can cause adverse effects such as sedation, peripheral edema, mood changes, confusion, and respiratory depression, particularly in older adults or those requiring additional analgesics.[99] Caution is especially warranted in older patients with diabetic neuropathy, as combining these medications with opioids significantly increases the risk of mortality.[100]

Selective serotonin reuptake inhibitors (SSRIs), such as duloxetine, may cause adverse effects, including mood changes, headaches, and nausea. They should be avoided or used with caution in patients with kidney or liver disease, and such individuals require close monitoring if duloxetine is prescribed.

Feared complications of opioid therapy include addiction, overdose leading to respiratory depression, and, in some cases, death. Another important concern is opioid-induced hyperalgesia, a condition in which patients become more sensitive to pain while on chronic opioid therapy.[101] Long-term risks and adverse effects of opioids include constipation, tolerance, physical dependence, nausea, dyspepsia, arrhythmia (such as QT prolongation with methadone), and opioid-induced endocrine dysfunction, which may manifest as amenorrhea, impotence, gynecomastia, reduced energy, and decreased libido. Additionally, there is a dose-dependent risk of overdose associated with increasing daily MMEs.

Complication rates for spinal cord stimulators range from 5% to 40%.[102][103] The most common issue is lead migration, which can result in inadequate pain relief and often necessitates surgical revision and lead anchoring.[104][105] Lead movement is particularly common in the cervical region due to the greater range of motion of the cervicovertebral joint.[106][107] Spinal cord stimulator lead fractures occur in up to 9% of placements.[108][109]

Seromas are also common after spinal cord stimulator placement and may require surgical incision and drainage.[102][110] The risk of infection following spinal cord stimulator placement ranges from 2.5% to 12%.[111][112] Although rare, direct spinal cord trauma can occur, with the most serious infectious complication being a spinal cord abscess. Dural puncture, though uncommon, may lead to a postdural headache in up to 70% of cases.[110][113][114] The most critical adverse event is spinal epidural hematoma, which occurs in approximately 0.71% of cases and requires urgent neurosurgical decompression.[115]

Postoperative and Rehabilitation Care

Discharge and postoperative instructions vary depending on the procedure and the physician's preferences. Following the placement of a temporary or permanent spinal cord stimulator, patients are typically advised to avoid overhead reaching for 6 weeks. Sutures or staples are typically removed around 14 days postoperatively, with wound care tailored to the specific procedure, the patient’s health status (such as diabetes and immunosuppression), and the surgeon’s discretion.

Consensus is lacking regarding the use of prophylactic antibiotics for implantable devices; however, a 5-day course of a second-generation cephalosporin is commonly prescribed. Incisional pain tends to be more significant following pain pump insertion than after spinal cord stimulator placement, although procedures involving paddle lead stimulators with microlaminectomy may produce similar pain levels. Short-term opioid therapy (3–7 days) is often recommended for postoperative pain, particularly in cases involving paddle leads.

Postoperative infections can occur with any procedure; however, spinal cord stimulators involve the epidural space. While epidural abscesses are serious, meningitis presents an even greater risk. Because pain pumps are placed in the subarachnoid space, clinicians should maintain a high index of suspicion for meningitis and have a low threshold for performing lumbar puncture and consulting infectious disease specialists.

Temporary and permanent pain pump insertions typically require an overnight hospital stay. However, some clinicians opt for a single short-acting opioid spinal injection to assess pain response, allowing discharge after 6 to 8 hours. While this approach is simpler and more cost-effective, it does not provide the advantage of evaluating how the device affects daily functioning and quality of life over an extended period.

Post-implant spinal headaches may occur due to accidental dural puncture during spinal cord stimulator placement or intentional subarachnoid catheter placement. A blood patch is often an effective treatment option. Although no formal guidelines exist, early intervention—such as placing a temporary patch the following day—may help preserve the trial. For permanent pain pump implants, using a purse-string suture around the catheter may reduce the risk of postprocedural headaches.

Pain Pump Idiosyncrasies

Pain pumps require postoperative “interrogation” with a handheld device used for programming and reprogramming. This device is owned by the manufacturer and is typically kept at the managing physician’s office. Surgical incision care is similar to that for laminectomy or total knee arthroplasty, often involving Silvercel or Aquacel dressings, although specific protocols may vary by surgeon.

Patients living in rural areas may be several hours away from their managing pain specialist. In such cases, a local provider—such as a primary care physician, emergency medicine physician, internist, or hematologist/oncologist—can assist with pump adjustments. A manufacturer’s technical representative can carry out programming based on the pain specialist’s orders; however, a licensed provider must be present to authorize and oversee the changes. Unlike spinal cord stimulators, pain pump representatives are not permitted to program or implement changes independently without physician supervision.

Although physicians' willingness may vary, most are willing to assist in order to spare patients from long and burdensome travel. While exceptions exist, manufacturer representatives typically bring the interrogator device to each visit and do not leave it behind. Currently, the primary manufacturer uses a Galaxy Tab Active Pro as the interrogator and a modified Samsung Galaxy A10 as the Patient Therapy Manager (PTM). All patients with pain pumps, particularly those also taking oral opioids, should have a family member trained in administering nasal Narcan.

Patients typically receive a PTM device for administering bolus doses of medication. Common settings include 3 to 5 boluses per 24-hour period, with a lockout interval of 90 to 120 minutes, and each bolus delivering 5% to 10% of the total daily dose. The PTM is generally activated once the pump has reached a stable state—usually 10 to 12 weeks after implantation—and is never enabled before suture removal.

Notably, the PTM can be adjusted to deliver higher bolus doses at shorter intervals for end-of-life care. Family members and hospice nurses may be trained to administer these doses. The PTM device also features an on-screen training video to guide users through proper operation.

Rehabilitation Medicine

Many interventional procedures are performed to support or enhance therapeutic outcomes. For example, a suprascapular nerve block with local anesthetic may be administered before occupational therapy for adhesive capsulitis to facilitate range of motion and participation. Similarly, the temporary pain relief achieved from an epidural steroid injection for discogenic pain can create an opportunity for focused core strengthening and rehabilitation efforts.

Rehabilitation strategies vary depending on the affected region, whether it is the spine, peripheral joints, or generalized myopathy. Certain exercises may need to be modified or avoided entirely, especially in cases of inflammatory myopathies, until muscle enzyme levels normalize to prevent further injury.

Although rehabilitation in chronic pain is a complex area, a foundational approach focuses on maintaining range of motion and function, building overall strength and bone density (for example, through weight-bearing exercises using light resistance such as soup cans), and improving cardiovascular fitness. These general goals establish a solid base while more targeted therapies are implemented.

Consultations

Chronic pain management requires a multidisciplinary approach, with consultations tailored to the underlying etiology. Any physician may be involved, with the extent of their participation tailored to the patient’s specific needs, comorbidities, and treatment goals.

Hematology and oncology: Consulted for malignancy-related pain management.

Obstetrics and gynecology: Involved in cases of pelvic pain, contraception planning, and management of pregnancy in patients using teratogenic medications or with complex spinal conditions (eg, post-laminectomy syndrome with a pain pump).

Interventional pain management: For regional nerve blocks, procedural interventions, spinal cord stimulators, and intrathecal pumps.

Psychiatry and psychology: To address depression, anxiety, and adjustment disorders, which are commonly associated with chronic pain.

Rheumatology: For DMARD management and clarification of autoimmune diagnoses.

Orthopedic surgery: Consulted for joint arthroplasty and non-spinal procedures, such as bursectomy.

Plastic surgery: Involved in nerve decompression, scar revision, burn management, and injectable enzyme treatments for scar tissue (eg, platysma).

Neurosurgery: Consulted for spinal pathology, spinal surgeries, and advanced interventions such as motor cortex stimulation, which involves implanting electrodes in the brain’s motor cortex to manage chronic, refractory pain.
Physical medicine and rehabilitation: Often leads initial pain evaluations and coordinates care with rheumatology and interventional pain specialists. Providers in this field may also manage prosthetic and brace assessments.
Prosthetics and orthotics: Provide braces and adaptive equipment to improve mobility and function.
Physical and occupational therapy: Provide therapeutic exercises, desensitization protocols, and training in the use of adaptive equipment. Physical therapists may also conduct TENS unit trials, including patient education, which is often required for insurance approval.

In cases involving spinal cord stimulators or pain pumps, manufacturer technical representatives play a crucial role in device programming, particularly during the first 12 weeks after implantation, as the leads settle and scar tissue forms. Seasonal changes, new injuries, and central sensitization often require reprogramming. Representatives are typically allowed to meet patients in healthcare settings, including hospital cafeterias, but not in private homes, with the managing physician notified. While representatives can perform programming for pain pumps, a licensed physician must finalize any changes by physically confirming them.

Many large institutions and regional spinal cord injury centers offer specialized “Seating and Positioning Clinics” for wheelchair measurement and customization, ensuring optimal fit and function for patients with spinal injuries. These clinics play a vital role in preventing pressure ulcers, improving posture, and enhancing mobility, ultimately improving overall quality of life.

Pastoral care supports the spiritual needs of patients, especially during end-of-life care. This service may overlap with psychiatric support and is typically tailored to reflect the patient’s individual religious beliefs and preferences.

Animal-assisted therapy has shown wide-ranging benefits across multiple areas of care. Hypoallergenic, non-shedding dogs are commonly used to provide comfort, ease anxiety, and offer distraction during procedures. These therapy animals can also enhance patient experiences by reducing perceived wait times in clinical settings.

Deterrence and Patient Education

Chronic pain is most effectively managed by an interprofessional team that includes a primary care physician and a specialist in pain management. Utilizing a multimodal approach enhances patient outcomes and minimizes reliance on high-risk treatments, such as opioids.

Medications should be titrated gradually according to the patient’s response and tolerance. Individuals on chronic opioid therapy should be routinely assessed for signs of misuse and offered addiction treatment when appropriate. Interventional procedures may be considered for patients who do not respond to medications or are interested in reducing or discontinuing opioid use.

Managing comorbid depression and anxiety is crucial for improving pain outcomes. In older adults, pain may be expressed differently, necessitating tailored assessment approaches. Following spinal cord stimulator placement, regular follow-up is essential to optimize device settings. Ongoing mental health monitoring, including screening for suicidal ideation, is a vital component of comprehensive chronic pain management.

Pearls and Other Issues

Key facts to keep in mind regarding chronic pain management are outlined below.

Multimodal approach: Combining pharmacological and nonpharmacological therapies offers better pain control.

Broad provider involvement: Nearly any healthcare practitioner may be involved, depending on the patient’s needs.

Interprofessional teamwork: Collaboration between primary care physicians and pain management specialists is essential for comprehensive care.

Medication management:
- Treatment should begin with non-opioid analgesics such as acetaminophen or NSAIDs.
- Narcan training and access should be provided to patients.
- Dosages should be increased gradually in a stepwise manner based on the patient's reported pain levels.
- Adjunct medications such as gabapentin, tramadol, and methadone should be used with caution due to potential adverse effects and interactions, including anticholinergic and serotonergic effects, as well as QT interval prolongation.
- If opioid misuse is suspected, medications for opioid use disorder should be offered.

Interventional procedures: These should be considered for patients with refractory pain or when aiming to reduce opioid use.

Psychological factors: Comorbid conditions such as depression, adjustment disorder, and anxiety should be identified and appropriately managed.

Reevaluation: Clinicians should assess for potentially treatable underlying causes, keeping in mind that early or atypical presentations of the disease may occur.

Older patients: Healthcare providers must recognize variations in pain expression and consider special management needs in this population.

Monitoring: Regular assessment for severe depression and suicidal ideation is essential in patients with chronic pain.

Opioid safety concerns:
- Clinicians should remain vigilant about risks such as addiction, overdose, and opioid-induced hyperalgesia.
- Awareness of long-term effects, including constipation, tolerance, and physical dependence.

Implantable technologies: These include pain pumps and spinal cord stimulators. Spinal cord stimulators require careful setup, patient education on use, and comprehensive perioperative management.

Enhancing Healthcare Team Outcomes

Chronic pain is a multifaceted condition that demands a coordinated, interprofessional approach involving nearly all areas of healthcare. Effective management depends on patient-centered care, continuous assessment, and close collaboration among physicians, advanced practitioners, nurses, pharmacists, and other allied healthcare professionals.

Healthcare providers must stay up to date on pain assessment techniques, evidence-based therapies, and the ethical delivery of care. Strategic management should begin with early evaluation and conservative interventions, escalating treatment only when clinically indicated. Pharmacists play a critical role in ensuring medication safety and monitoring for potential drug interactions, particularly in cases involving chronic opioid use or polypharmacy.

Clear communication and coordination among healthcare team members—facilitated through meetings, case reviews, and shared documentation—are essential for aligning treatment goals and ensuring timely interventions. Nurses play a critical role in monitoring patient progress, managing adverse effects, providing education, and advocating for appropriate resources and support.

Patients require consistent follow-up across care settings. Special attention should be given to medication reconciliation, as patients may use unreported over-the-counter or herbal remedies that could interact with prescribed treatments. Vulnerable populations, particularly older adults or those with cognitive impairment, are at risk of receiving misleading information online, which may discourage transparency with healthcare providers or family members.

By strengthening clinical skills, fostering effective communication, and coordinating care, healthcare teams can improve outcomes, enhance patient safety, and provide ethical, evidence-based chronic pain management. This collaborative approach fosters patient trust, minimizes care fragmentation, and promotes long-term adherence to treatment plans.

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