Chronic Pain Management (CDC 2022 Guidelines)

Algorithm Steps

1. ▶

   Start

   Chronic Pain Assessment

   Pain lasting >3 months or beyond expected healing

   1. ●

      Action

      Comprehensive Pain Evaluation

      Multimodal assessment

      • Pain history: location, intensity (0-10), quality, timing
      • Functional impact: work, ADLs, sleep, mood
      • Prior treatments and response
      • Screen for depression, anxiety (common comorbidities)
      • Assess opioid risk (ORT, SOAPP-R)
      1. ◆

         Decision

         Pain Type Classification

         Guide treatment selection

         • Nociceptive: Mechanical/inflammatory (OA, low back)
         • Neuropathic: Burning, shooting (diabetic, post-herpetic)
         • Nociplastic: Central sensitization (fibromyalgia)
         • Mixed: Often has components of multiple types
         1. ●

            Action

            Non-Pharmacologic First

            Foundation of chronic pain treatment

            • Physical therapy / exercise
            • Cognitive behavioral therapy for pain
            • Mindfulness-based stress reduction
            • Acupuncture (moderate evidence)
            • Massage, heat, cold therapy
            • Weight loss if applicable
            1. ●

               Action

               Ongoing Monitoring

               Required for all chronic pain management

               • Reassess pain and function regularly
               • Check PDMP before each opioid prescription
               • Urine drug screen periodically
               • Assess for opioid use disorder (DSM-5)
               • Document risk-benefit at each visit
               1. ◆

                  Decision

                  Functional Improvement?

                  Goals met with acceptable side effects

                  1. ✓

                     Outcome

                     Continue Current Therapy

                     Maintain at lowest effective dose

                  2. ●

                     Action

                     Modify Approach

                     If not improving or adverse effects

                     • Add non-pharmacologic modalities
                     • Rotate medications
                     • Consider specialty referral (pain clinic)
                     • If on opioids: slow taper if not beneficial
                     • Address psychosocial factors
               2. ⚠

                  Warning

                  OUD Concern

                  Signs of opioid use disorder

                  • Craving, loss of control, continued use despite harm
                  • Offer evidence-based treatment: buprenorphine, naltrexone
                  • Refer to addiction medicine if complex
                  • Do not abruptly discontinue opioids
                  • Harm reduction approach
         2. ●

            Action

            Non-Opioid Pharmacotherapy

            First-line medications

            • NSAIDs/acetaminophen for nociceptive pain
            • Duloxetine/venlafaxine for neuropathic/nociplastic
            • Gabapentin/pregabalin for neuropathic
            • TCAs (amitriptyline) low-dose for neuropathic
            • Topical lidocaine, capsaicin
            1. ◆

               Decision

               Consider Opioids?

               Only if benefits outweigh risks

               • Non-opioid options inadequate or contraindicated
               • Functional goals clear
               • No active substance use disorder
               • Benefits expected to outweigh risks
               1. ⚠

                  Warning

                  Opioid Initiation (If Indicated)

                  CDC 2022 guidance

                  • Start lowest effective dose (≤50 MME/day)
                  • Immediate-release before extended-release
                  • Avoid ≥90 MME/day without careful reassessment
                  • Co-prescribe naloxone if ≥50 MME or risk factors
                  • Written treatment agreement recommended