Management of Chronic Non-Cancer Pain: a Framework

Abstract

Aim: Since publication of the CDC 2016 Guideline, opioid-related mortality in the USA has doubled and a crisis has developed among the 15–20 million Americans with chronic, moderate-to-severe, noncancer pain. Our aim was to develop a comprehensive alternative approach to management of chronic pain. Methods: Analytic review of the clinical literature. Results: Published science provides a solid framework for the management of chronic non-cancer pain, detailed here, even as it leaves many knowledge gaps, which we fill with insights from clinical experience. Conclusion: There is a sufficient basis in science and in clinical experience to achieve adequate control of chronic pain in nearly all patients in a way that adequately balances benefits and potential harms.

Plain language summary

Opioid-related mortality in the USA continues to increase rapidly despite the decline in opioid prescriptions achieved by the CDC 2016 Guideline. This Guideline has also created a crisis among the 15–20 million Americans with chronic, moderate-to-severe, noncancer pain. We offer a detailed framework for an alternative approach to management of chronic pain. We also offer some suggestions for solving the problem of illicit drug use, which now accounts for 84% of opioid-related deaths. To the extent possible, we have relied upon published science. However, we also identify many knowledge gaps that we address with insights from clinical experience and thousands of interactions with patients. These knowledge gaps will ultimately need to be addressed by further research.

Keywords::

• benzodiazepines
• CDC guideline
• chronic pain
• illicit opioids
• neuralgic pain
• neuropathic pain
• opioid crisis
• opioids
• pain management
• somatic pain

Acknowledgments

The authors are deeply grateful to all of the patients over the decades who taught us so much about the management of chronic pain and we regret the suffering we could not alleviate.

Disclaimer

The contents of this manuscript do not represent the views of the US Department of Veterans Affairs, the United States Government or the University of Florida.

Financial & competing interests disclosure

This work was supported by resources provided by the North Florida/South Georgia Veterans Health System (FL, USA). It was not supported by a specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Additional information

Funding

This work was supported by resources provided by the North Florida/South Georgia Veterans Health System (FL, USA). It was not supported by a specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.