Updated October 2025

Clinical Playbook

Evidence-Based Management of Chronic Pain

A multimodal, patient-centered framework emphasizing non-pharmacological first-line care, judicious pharmacotherapy, careful opioid stewardship, and functional rehabilitation, integrating the best available evidence from systematic reviews and contemporary guidelines.

Clinical question

What are the most effective, evidence-based strategies for assessment and management of chronic non-cancer pain to improve pain intensity, function, and quality of life while minimizing harms?

Chronic PainPrimary CareMultimodal AnalgesiaOpioid StewardshipBehavioral TherapyOlder AdultsDigital Health

Key points

Comprehensive assessment first

Use biopsychosocial evaluation, classify chronic primary vs secondary pain, and set functional goals; screen for mood, sleep, and substance use disorders ^[2], ^[1].

Prioritize non-pharmacologic therapies

Exercise therapy, CBT/ACT, and mind–body practices yield small-to-moderate improvements in pain and function with low harm profiles ^[3], ^[6].

Non-opioid pharmacotherapy before opioids

Condition-directed use of NSAIDs, acetaminophen, antidepressants, and anticonvulsants with routine reassessment of benefit–risk ^[2], ^[1].

Opioid stewardship when needed

Careful indication, lowest effective dose, time-limited trials, and frequent monitoring; taper if harms outweigh benefits ^[1].

Leverage multidisciplinary and digital augmentation

Team-based rehab and validated eHealth programs can enhance access, adherence, and outcomes, especially where in-person services are limited ^[7], ^[5].

Evidence highlights

Non-pharmacologic and non-opioid therapies per major guidelines ^[1], ^[2]

First-line focus

Acceptance-based interventions improve pain, depression, and anxiety (small–moderate effects) ^[3]

Behavioral therapies

Analgesics and non-drug strategies reduce pain in residents ≥60 years ^[4]

Care homes

eHealth shows small but meaningful benefits; heterogeneity remains ^[5]

Digital tools

Framework

Stepwise, Multimodal Care Pathway

Emphasize function-centered goals, shared decision-making, and iterative outcome tracking.

Classify pain type and drivers

Differentiate chronic primary vs secondary pain; identify nociceptive, neuropathic, and nociplastic contributions. Screen for depression/anxiety, sleep disturbance, catastrophizing, and substance use. Establish patient-prioritized, measurable functional goals ^[2], ^[1].

Initiate non-pharmacologic core therapies

Prescribe graded exercise/physical therapy, CBT or ACT, and sleep hygiene; consider yoga, tai chi, acupuncture, and manual therapies as adjuncts. Evidence supports small–moderate improvements across outcomes with low risk ^[6], ^[3].

Add non-opioid pharmacologic agents as indicated

Use condition-specific choices (e.g., SNRIs or TCAs for neuropathic features; topical NSAIDs for osteoarthritis; cautious NSAID use for nociceptive pain). Reassess pain, function, and adverse effects regularly ^[2], ^[1].

Consider interventional options selectively

For targeted secondary pain (e.g., facet-mediated, radicular), consider injections or procedures after conservative therapy, with clear functional endpoints and time-limited trials. Evidence quality varies by indication.

Reserve and monitor opioid therapy

If benefits clearly outweigh risks after optimized non-opioid care, initiate a time-limited opioid trial at the lowest effective dose, with functional criteria for continuation, PDMP checks, risk mitigation, and naloxone where appropriate. Taper if benefits do not sustain or if harms emerge ^[1].

Augment with multidisciplinary and digital supports

Refer to interdisciplinary pain programs where feasible; integrate validated digital CBT/ACT and self-management apps to support adherence and access ^[7], ^[5].

Implementation

Assessment, Treatment Selection, and Monitoring

Key elements to operationalize evidence-based care across settings, including older adults and long-term care.

Core assessment

Classify chronic primary vs secondary pain; map pain mechanisms ^[2]

Baseline PROMs: pain intensity, interference, function (e.g., PEG, ODI)

Psychological screening: depression/anxiety, catastrophizing; sleep; SUD ^[1], ^[2]

Risk stratify for opioid-related harms (history of SUD, OSA, renal/hepatic disease) ^[1]

Non-pharmacologic first-line

Exercise/graded activity with pacing principles; physical therapy

CBT or ACT: acceptance-based therapies show small–moderate effects on pain, depression, anxiety; Hedges g ≈ 0.37–0.48 across outcomes ^[3]

Mind–body: yoga, tai chi, mindfulness; acupuncture and manual therapies as adjuncts ^[6]

Sleep interventions; education on pain neuroscience and flare management

Non-opioid pharmacotherapy

Neuropathic features: SNRIs (duloxetine), TCAs (nortriptyline), gabapentinoids with monitoring

Nociceptive OA: topical NSAIDs first; oral NSAIDs short-term with GI/CV risk mitigation; acetaminophen limited benefit but low risk

Topicals (lidocaine, capsaicin) for focal neuropathic or OA pain

Avoid routine long-term benzodiazepines or muscle relaxants

Opioid stewardship

Consider only after optimized non-opioid care and if benefits outweigh risks; document functional goals ^[1]

Start low, reassess within 1–4 weeks; continue only with clinically meaningful improvement in pain/function and no serious harms ^[1]

Avoid high doses; prefer immediate-release; PDMP checks; urine drug testing when indicated; offer naloxone for overdose risk ^[1]

If tapering: collaborative, slow reductions; address withdrawal and pain flares; integrate behavioral support ^[1]

Older adults and long-term care

Use non-drug and analgesic strategies that show effectiveness in care homes; tailor to frailty and polypharmacy ^[4]

Prefer topical agents; cautious NSAID use; start low/go slow with TCAs/SNRIs/gabapentinoids

Prioritize fall prevention, cognition, constipation management; involve caregivers

Functional goals (mobility, ADLs) as primary endpoints

Complex contexts

Opioid substitution treatment populations: high CP prevalence; coordinate pain and SUD care ^[8]

Co-occurring PTSD/depression: integrate trauma-informed behavioral therapies; ACT/CBT beneficial ^[3]

Veterans/armed conflict: biopsychosocial approaches aligned with functional rehabilitation ^[9]

Escalate to multidisciplinary programs for refractory disability ^[7]

Digital and remote care

Use validated eHealth CBT/ACT programs; evidence supports small but meaningful improvements in pain/function and access ^[5]

Set expectations; combine with clinician follow-up to enhance adherence

Leverage remote monitoring of PROMs to guide titration and stepped care

Outcomes

Measuring Benefit and Harm

Track multi-domain outcomes to guide continuation, modification, or de-escalation.

Primary outcomes

≥30% improvement in pain intensity or interference

Functional gains relevant to patient goals (mobility, ADLs, work)

Quality of life and sleep metrics

Harms and safety

Medication AEs (falls, cognition, GI/CV/renal, serotonin syndrome)

Opioid-related risks (overdose, OUD); monitor with PDMP and UDT when appropriate ^[1]

Psychological distress or worsening mood; address promptly

Evidence Highlights

Key Data Points to Inform Decisions

Synthesis across systematic reviews and guidelines.

Acceptance-based and psychological therapies

Systematic review/meta-analysis shows small–moderate effects on pain and distress in chronic pain populations (e.g., Hedges g ~0.37–0.48 across pain, depression, anxiety), supporting routine inclusion as core therapy ^[3].

Care home residents ≥60 years

Updated review/meta-analysis: analgesic drugs and non-drug strategies were the most effective for reducing pain; interplay with frailty and polypharmacy requires cautious selection and monitoring ^[4].

Digital health

Meta-review indicates eHealth interventions confer small but meaningful benefits for patients and systems; heterogeneity and durability vary, but they are valuable adjuncts where access is limited ^[5].

Guideline alignment

Major guidance recommends non-pharmacologic and non-opioid therapies first, with structured opioid decision-making, dose limits, and tapering guidance when needed ^[2], ^[1].

Multidisciplinary programs

Systematic review suggests that a standardized multidisciplinary approach yields generally good outcomes and should be widely implemented when available ^[7].

References

Source material

Primary literature that informs this article.