Pain type guides medication prescribed

Somatic (nociceptive) pain: Acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs – caution in older adults) and opioids (long-acting preferred); trial of adjuvants (see Table 2) for refractory symptoms.

Neuropathic pain: Serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), anticonvulsants, lidocaine patch, tramadol and opioids. (SSRIs and NSAIDs often ineffective.)

Centralized pain/Fibromyalgia: TCAs (amitriptyiline, cyclobenzaprine), SNRIs (duloxetine) and alpha-2-delta ligands (pregabalin and gabapentin) are effective for conditions such as fibromyalgia. Serotonin-selective reuptake inhibitors (SSRIs) can also be useful. (Opioids are not indicated.)

Medication Treatment


Choose  drugs  based  on  presumed  pain  type  and  the  patient’s  comorbidities. 
-  NSAIDs and/or acetaminophen can be effective for chronic musculoskeletal or arthritis pain. In older adults, NSAIDs and COX-2 inhibitors should be used rarely and with caution, monitoring for GI and renal toxicity, hypertension, and heart failure. [1D]*  
-  Adjuvant medications Tricyclics (TCAs), SNRIs (duloxetine) and second generation anticonvulsant medications are effective for specific neuropathic pain states. [1A]* For centralized pain/fibromyalgia, TCAs, SNRIs, gabapentin and pregabalin are effective. [1A]*  
-  Opioid analgesics can be safe and effective for some patients with chronic non-terminal pain [I1B]*, but require careful patient selection, titration and monitoring. Scheduled, long-acting opioids, (morphine ER, or methadone, buprenorphine) are preferred for continuous treatment [ID]*. OxyContin has a higher risk for misuse or diversion. Avoid long-term, daily treatment with short-acting opioids and opioid combinations (e.g., Vicodin, Norco, Percocet). For  “as  needed”  (PRN)  dosing,  prescribe  small  amounts  expecting  monthly  (not  daily)  use.