Korean J Pain.  2010 Jun;23(2):99-108. 10.3344/kjp.2010.23.2.99.

Pharmacologic Management of Chronic Pain

• Park HJ
• Moon DE

• KMID: 1770541
• DOI: http://doi.org/10.3344/kjp.2010.23.2.99

Abstract

Chronic pain is a multifactorial condition with both physical and psychological symptoms, and it affects around 20% of the population in the developed world. In spite of outstanding advances in pain management over the past decades, chronic pain remains a significant problem. This article provides a mechanism- and evidence-based approach to improve the outcome for pharmacologic management of chronic pain. The usual approach to treat mild to moderate pain is to start with a nonopioid analgesic. If this is inadequate, and if there is an element of sleep deprivation, then it is reasonable to add an antidepressant with analgesic qualities. If there is a component of neuropathic pain or fibromyalgia, then a trial with one of the gabapentinoids is appropriate. If these steps are inadequate, then an opioid analgesic may be added. For moderate to severe pain, one would initiate an earlier trial of a long term opioid. Skeletal muscle relaxants and topicals may also be appropriate as single agents or in combination. Meanwhile, the steps of pharmacologic treatments for neuropathic pain include (1) certain antidepressants (tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors), calcium channel alpha2-delta ligands (gabapentin and pregabalin) and topical lidocaine, (2) opioid analgesics and tramadol (for first-line use in selected clinical circumstances) and (3) certain other antidepressant and antiepileptic medications (topical capsaicin, mexiletine, and N-methyl-d-aspartate receptor antagonists). It is essential to have a thorough understanding about the different pain mechanisms of chronic pain and evidence-based multi-mechanistic treatment. It is also essential to increase the individualization of treatment.

Keyword

chronic pain; pharmacologic management

MeSH Terms

Analgesics, Opioid
Antidepressive Agents
Calcium Channels
Capsaicin
Chronic Pain
Fibromyalgia
Lidocaine
Ligands
Mexiletine
N-Methylaspartate
Neuralgia
Neuromuscular Agents
Norepinephrine
Pain Management
Serotonin
Sleep Deprivation
Tramadol
Analgesics, Opioid
Antidepressive Agents
Calcium Channels
Capsaicin
Lidocaine
Ligands
Mexiletine
N-Methylaspartate
Neuromuscular Agents
Norepinephrine
Serotonin
Tramadol

Figure

• 

  Fig. 1 Treatment algorithm for pharmacotherapy of chronic noncancer pain. In general, if one agent in a class of medications does not provide adequate analgesia or causes limiting side effects, it is worth pursuing serial trials of 1 or 2 others from the class. Topicals may be introduced at any point as a sole agent or in combination.

• 

  Fig. 2 The Vicious Circle showing interaction of influencing factors.

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