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Pain Management Algorithm

Pdf Summary

The document provides a pain management algorithm from the Compass Opioid Prescribing Treatment Guidance Toolkit, emphasizing appropriate classification of chronic non-cancer pain (CNCP) and prioritizing non-opioid strategies. It explains that CNCP has traditionally been viewed as nociceptive (e.g., osteoarthritis, rheumatoid arthritis) or neuropathic (e.g., diabetic neuropathy, post-herpetic neuralgia), which often leads to peripheral treatments such as injections, surgery, topical therapies, and sometimes opioids.<br /><br />However, the toolkit highlights “central pain” or central sensitization (CS) as a distinct and increasingly recognized driver of chronic pain. Fibromyalgia is presented as the classic example, but CS is described as a spectrum that may contribute to chronic headaches and chronic low back pain. Because exams, labs, and imaging may be inconclusive in CS, the guidance stresses careful history-taking, symptom review, and use of validated screening tools (e.g., CSI and PSQ). It also recommends screening for common comorbidities—anxiety, depression, PTSD, and substance use disorders—given their high prevalence in CS.<br /><br />Treatment of centralized pain should focus on behavioral interventions, sleep and stress management, and dietary changes; repeated imaging, procedures, injections, and opioids are described as ineffective and potentially harmful. If medications are used, centrally acting agents such as tricyclic antidepressants (TCAs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) may help.<br /><br />Overall chronic pain is framed as a biopsychosocial condition. Cognitive behavioral therapy (CBT) is identified as the gold-standard, first-line treatment and should become the backbone of care when pain transitions from acute to chronic. Evidence cited suggests opioids offer limited benefit in acute pain and even less in chronic pain, while sleep restoration, physical activity, and mindfulness provide better long-term outcomes.<br /><br />The included stepwise algorithm recommends: first-line nonpharmacologic care plus NSAIDs/acetaminophen and topical agents; condition-appropriate agents (gabapentinoids, SNRIs, TCAs) for neuropathic/mixed pain; second-line add-ons and specialist referral when needed; and third-line options such as short-term muscle relaxers, interventional therapies, and only a short (about 7 days) opioid trial for breakthrough pain, preferring single-ingredient opioids to allow scheduled acetaminophen.

Keywords

chronic non-cancer pain

central sensitization

fibromyalgia

opioid prescribing

cognitive behavioral therapy

non-opioid strategies

neuropathic pain

SNRIs

TCAs

pain management algorithm