# Chronic Pain

Chronic pain management requires phenotype-based assessment, functional goal setting, and multimodal treatment while avoiding reflexive long-term opioid escalation. Identify secondary pain generators, neuropathic features, co-occurring mental health or substance use disorders, and treatment-limiting harms before selecting pharmacologic, rehabilitative, behavioral, or procedural care.

**Clinical question:** How should clinicians assess and manage chronic pain while prioritizing function, nonopioid therapies, and opioid safety?

Updated: 2026-08-24T18:31:16.293294+00:00

## What matters in practice
- Classify the pain phenotype and identify a potentially treatable secondary cause before treating pain intensity alone; neuropathic, nociceptive, and mixed patterns require different therapeutic pathways. [19][23][24]
- Use function, participation, sleep, and treatment harms as longitudinal outcomes rather than relying only on a numeric pain score. [21][22]
- For chronic pain, prioritize nonpharmacologic and nonopioid strategies; long-term opioid benefit is limited or uncertain, whereas tolerance, sedation, dependence, and overdose risk remain clinically important. [1][7][8]
- If opioids are continued, reassess benefit and safety regularly, evaluate for opioid use disorder, and use structured monitoring tools such as urine drug testing, pill counts, and overdose-risk assessment. [5][6][14]

## Identify urgent secondary causes before chronic pain management

Do not attribute persistent pain to chronic primary pain until a dangerous or remediable pain generator has been considered.

Begin by determining whether the presentation is chronic secondary pain, chronic primary pain, or both. Chronic primary pain is pain without a clear underlying cause or pain whose impact is disproportionate to observable injury or disease; this distinction changes whether the next action is disease-directed evaluation versus symptom-focused rehabilitation and behavioral treatment. [24]

Escalate diagnostic evaluation when the history or examination suggests a structural, inflammatory, malignant, infectious, neurologic, or visceral process that could alter treatment. For low back pain, distinguish axial mechanical pain from radicular symptoms because the evidence base and treatment comparisons differ for radicular low back pain versus acute, subacute, and chronic nonradicular low back pain. [10]

Document pain distribution, temporal pattern, quality, aggravating and relieving factors, sensory symptoms, motor deficits, sleep disruption, mood symptoms, activity restriction, current analgesics, substance use history, and prior response to active rehabilitation, psychological treatment, injections, surgery, or opioids. Disease-specific functional scales and neuropathic pain screening instruments can complement the interview and physical examination when pain mechanisms are uncertain. [19][21][22][23]
- Treat new focal neurologic deficits, progressive weakness, bowel or bladder dysfunction, systemic illness, rapidly progressive pain, or concern for infection, cancer, fracture, or ischemia as indications for urgent cause-directed evaluation rather than routine chronic-pain escalation.
- Use a structured baseline outcome set: pain intensity, a patient-selected functional activity, sleep, work or role participation, adverse effects, and medication exposure. Questionnaires can help distinguish nociceptive from neuropathic features in complex pain syndromes. [21][22]
- Ask whether pain is aching, stabbing, burning, electric, or accompanied by sensory change; pain character helps classify nociceptive, neuropathic, or mixed pain and directs subsequent treatment selection. [23]

*Pain phenotype should determine the next diagnostic and treatment step. [19][23][24]*

| Clinical pattern | Key discriminator | Immediate next step |
| --- | --- | --- |
| Chronic secondary pain | An identifiable disease or injury plausibly accounts for pain and its impact. [24] | Pursue disease-specific assessment and treatment while addressing function and analgesia. |
| Chronic primary pain | No clear underlying cause, or impact appears out of proportion to observable injury or disease. [24] | Shift treatment targets toward function, self-management, behavioral interventions, and nonopioid multimodal care. |
| Neuropathic or mixed pain | Pain descriptors and screening tools suggest neuropathic features. [19][22][23] | Confirm the relevant neurologic or regional pain generator and select mechanism-informed therapy rather than escalating nonspecific analgesics. |
| Radicular low back pain | Radiating symptoms distinguish it from nonradicular low back pain in treatment evidence. [10] | Use the radicular pathway; do not assume interventions effective for nonradicular pain have the same benefit. |

## Set functional targets before adding or continuing analgesics

A treatment trial should have a defined target, duration, and stopping rule.

Establish one or more observable functional goals before initiating or changing therapy: walking tolerance, return to a specific work task, sleep continuity, self-care, or participation in rehabilitation. Numeric pain ratings remain useful for tracking symptoms, but disease-specific and patient-specific functional scales provide a more decision-relevant measure of whether treatment is improving daily life. [21][22]

Use a biopsychosocial formulation when pain severity, disability, and emotional distress are discordant with structural findings or when multiple contributors coexist. Psychological therapies and multidisciplinary rehabilitation are among the evaluated nonpharmacologic options for chronic low back pain, alongside exercise, motor-control exercise, Pilates, tai chi, yoga, acupuncture, massage, and spinal manipulation. [10]

Avoid treating chronic pain as a medication-only problem. Nonpharmacologic strategies, including cognitive behavioral therapy and exercise therapy, are alternatives to opioid-centered care and are particularly relevant when the primary treatment objective is restoration of function rather than short-term analgesia. [3]
- At each follow-up, continue a treatment only if the preselected functional outcome, tolerability, and patient priorities support continuation.
- If disability persists despite low pain ratings, target deconditioning, fear avoidance, mood symptoms, sleep disruption, and workplace or caregiving barriers rather than increasing analgesic exposure alone.
- If pain improves without functional improvement, reassess the diagnosis, goals, sedation burden, depression, sleep disturbance, and the feasibility of active rehabilitation.

*Use treatment selection to match the dominant barrier to function. [3][10][21][22]*

| Dominant clinical barrier | Management emphasis | Outcome to monitor |
| --- | --- | --- |
| Movement-related disability | Exercise-based therapy, including motor-control exercise, Pilates, tai chi, or yoga when clinically appropriate for chronic low back pain. [10] | Selected activity tolerance and participation. |
| Fear, distress, maladaptive coping, or pain-related avoidance | Psychological therapy, including cognitive behavioral therapy; consider multidisciplinary rehabilitation when needs span physical and psychological domains. [3][10] | Avoidance behavior, treatment engagement, function, and sleep. |
| Localized musculoskeletal symptoms with uncertain benefit from passive modalities | Discuss acupuncture, massage, or spinal manipulation as options evaluated for chronic low back pain; reassess against functional goals. [10] | Short-term symptom change and functional carryover. |
| Complex pelvic or regional pain syndrome | Use pain scales, questionnaires, and focused examination to characterize pain, muscle tenderness, urinary symptoms, and neuropathic features. [22] | Mechanism-specific symptoms and patient-defined functional outcomes. |

## Build multimodal care around active nonopioid treatment

Select interventions by pain phenotype, functional barrier, and harms rather than by a universal analgesic ladder.

For chronic low back pain, nonpharmacologic options evaluated by the American College of Physicians include exercise, motor-control exercise, Pilates, tai chi, yoga, psychological therapies, multidisciplinary rehabilitation, acupuncture, massage, and spinal manipulation. The appropriate choice depends on patient preference, availability, physical capacity, prior response, and whether the intervention advances a specific activity goal. [10]

Pharmacologic care should be phenotype-specific and periodically reassessed for harm. The evidence review for low back pain separately evaluates pharmacologic therapies and adverse events for acute, chronic, and radicular pain, underscoring that a medication strategy should not be extrapolated automatically across pain syndromes. [10]

For chronic primary pain, avoid repeatedly searching for a purely structural explanation when assessment supports pain with no clear underlying cause or disproportionate impact. Use a coordinated plan that validates symptoms while directing care toward function, physical activity, psychological treatment, and reduction of iatrogenic medication burden. [24]
- Choose an active therapy when the primary deficit is mobility, conditioning, or confidence with movement; use passive modalities only as an adjunct if they enable participation in active treatment. [10]
- When resources are constrained, identify access barriers explicitly: behavioral and integrative chronic-pain services have substantial variation in Medicaid coverage across states. [4]
- For co-occurring chronic pain and opioid use disorder, integrate behavioral and medical care rather than attempting to manage either condition in isolation. [4][15]

*Nonpharmacologic options evaluated for chronic low back pain. [10]*

| Intervention category | Examples | Selection consideration |
| --- | --- | --- |
| Movement-based treatment | Exercise, motor-control exercise, Pilates, tai chi, yoga. [10] | Use when the plan includes a measurable mobility, endurance, or participation target. |
| Psychological and interdisciplinary care | Psychological therapies and multidisciplinary rehabilitation. [10] | Prioritize when distress, avoidance, disability, or multiple biopsychosocial contributors limit recovery. |
| Adjunctive nonpharmacologic modalities | Acupuncture, massage, spinal manipulation. [10] | Use as a time-limited trial only if it supports the patient’s active functional plan. |
| Radicular pain pathway | Exercise, traction, and other therapies are evaluated separately for radicular low back pain. [10] | Confirm radicular features before applying evidence from chronic nonradicular low back pain. |

## Reserve long-term opioids for carefully selected, monitored patients

Opioid continuation is a longitudinal benefit-risk decision, not a response to persistent pain intensity alone.

Long-term opioid administration has minimal effects on chronic pain and can produce tolerance, drowsiness, dependence, and impaired function. Reliable conclusions about long-term effectiveness have also been limited by sparse research. These limitations support prioritizing nonopioid and nonpharmacologic treatment before initiating chronic opioid therapy. [1][7]

Prescription opioid overdose and overdose death can occur even at low opioid dosage levels; risk rises with greater dose and with as-needed prescribing. Therefore, any opioid trial or continuation plan should specify the functional indication, anticipated duration, adverse-effect review, and conditions for tapering or discontinuation. [8]

Use chronic opioid therapy only after explicit patient selection, risk stratification, informed consent, and an opioid management plan. Prior guidance emphasizes monitoring for adverse effects and outcomes related to abuse potential, addiction, and diversion in addition to analgesic benefit. [14]

Screen for opioid use disorder when opioid treatment is ineffective, use becomes compulsive or unsafe, or there are concerning behavioral or monitoring findings. Features of opioid use disorder have been reported in more than 25% of patients receiving opioids for chronic pain, making routine clinical vigilance essential. [5]
- Before initiating or renewing long-term opioids, document the pain diagnosis, functional goal, prior nonopioid and nonpharmacologic trials, psychiatric and substance use history, current sedating medications, and overdose risk.
- Use structured monitoring proportional to risk, including urine drug testing, pill counts, and clinical review of adherence and harms. RIOSORD is a tool for estimating the risk of serious opioid-induced respiratory depression or overdose in opioid-treated patients. [6]
- Do not interpret an abnormal monitoring result as proof of diversion or opioid use disorder without confirming medication history, laboratory methodology, and the clinical context. Urine drug testing requires attention to both communication and test interpretation. [6]
- If opioid use disorder is identified or strongly suspected, arrange evidence-based opioid use disorder treatment while continuing to address pain and functional impairment. [4][15]

### Tapering or discontinuation

Consider dose reduction or discontinuation when opioid harms outweigh functional benefit, when dangerous adverse effects or unsafe use emerge, or when the original indication no longer justifies exposure. Tapering is a clinical transition that requires reassessment of pain, function, withdrawal risk, mental health, and possible opioid use disorder rather than abrupt removal of care. [9][14]
- Pair any opioid reduction plan with an alternative pain-management plan, including active rehabilitation, behavioral treatment, and nonopioid options appropriate to the pain phenotype. [3][10]
- Increase follow-up intensity during dose changes when overdose risk, psychiatric instability, or opioid use disorder features are present. [5][6]

*Structured decisions for patients receiving long-term opioid therapy. [5][6][8][14]*

| Finding at reassessment | Interpretation | Next action |
| --- | --- | --- |
| Meaningful functional benefit without unacceptable harms | Benefit may justify continued treatment only with ongoing safety monitoring. [14] | Continue the lowest-risk regimen consistent with goals; reassess function, sedation, adherence, and overdose risk. |
| Pain persists but function does not improve | Escalating opioid exposure is unlikely to address the main treatment failure given limited long-term benefit. [1][7] | Reassess phenotype and shift toward active nonopioid and behavioral therapies. |
| Sedation, tolerance, impaired function, or other opioid adverse effects | Known harms may outweigh analgesic benefit. [1][14] | Reevaluate the regimen and consider dose reduction or discontinuation with alternative treatment support. [9] |
| Concerning use pattern or suspected opioid use disorder | Chronic pain treatment may coexist with opioid use disorder; OUD features are reported in more than 25% of chronic-pain opioid recipients. [5] | Perform diagnostic assessment and link the patient to integrated pain and OUD care. [4][15] |
| High respiratory-depression or overdose risk | Overdose can occur at low doses and rises with dose and as-needed prescribing. [8] | Use structured risk assessment such as RIOSORD and intensify monitoring. [6] |

## Use procedures and specialty referral only for a defined indication

Escalate when the diagnosis, treatment target, and expected benefit are sufficiently specific to justify procedural risk.

For persistent spine-related pain, distinguish a disease-directed intervention from broad escalation of chronic pain care. Prior injections, radiofrequency ablation, spine surgery, and nonpharmacologic treatments are components of conventional medical management in comparative spinal cord stimulation research, but their use should follow a specific pain generator and treatment rationale rather than nonspecific refractory pain. [2]

Spinal cord stimulation evidence requires cautious patient selection. Some studies report pain benefit at 6 months compared with conventional medical management, but benefits often dissipate after 12 to 24 months; placebo-controlled studies show smaller effects, and long-term randomized evidence has been limited. [2]

Refer for multidisciplinary pain care when pain phenotype remains unclear, function continues to decline despite an organized nonopioid plan, opioid tapering is complicated by suspected opioid use disorder, or a procedure is being considered without a well-defined diagnostic target. Multidisciplinary rehabilitation is an evaluated option for chronic low back pain and may be preferable to serial passive interventions when disability has multiple drivers. [10][15]
- Before referral for spinal cord stimulation, document the specific neuropathic or spine-related indication, prior active and medical treatments, functional goals, psychological and substance use assessment, and the patient’s understanding that durable benefit is uncertain. [2]
- Avoid presenting neuromodulation as a proven replacement for comprehensive medical management; evidence of superiority over usual care has important limitations. [2]
- Use specialty evaluation to refine a differential or execute a disease-directed treatment plan, not as a substitute for baseline functional assessment and longitudinal outcome tracking. [21][22]

*Escalation choices should be linked to a defined clinical objective. [2][10][15]*

| Escalation scenario | Appropriate objective | Key tradeoff |
| --- | --- | --- |
| Multidisciplinary rehabilitation | Address persistent disability with physical and psychological contributors. [10] | Requires patient engagement and service access but targets function beyond analgesia. |
| Interventional spine procedure | Treat a defined structural or pain-generator hypothesis. | Avoid serial procedures when diagnostic specificity and functional benefit are absent. |
| Spinal cord stimulation | Consider only after careful selection for a defined indication and informed discussion. [2] | Reported short-term benefit may diminish after 12 to 24 months; placebo-controlled effects are smaller. [2] |
| Integrated pain and OUD care | Treat concurrent chronic pain and opioid use disorder. [4][15] | Coverage and access to behavioral and integrative services vary substantially. [4] |

## References
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## Editorial note

Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.