Chronic pain: an update on burden, best practices, and new advances

Chronic pain: an update on burden, best practices, and new advances

The Lancet
Claim
Access provided by
If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
Email*
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Affiliations
Johns Hopkins School of Medicine, Baltimore, MD, USA
Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
Next ArticleNociplastic pain: towards an understanding of prevalent pain conditions
Summary
Chronic pain exerts an enormous personal and economic burden, affecting more than 30% of people worldwide according to some studies. Unlike acute pain, which carries survival value, chronic pain might be best considered to be a disease, with treatment (eg, to be active despite the pain) and psychological (eg, pain acceptance and optimism as goals) implications. Pain can be categorised as nociceptive (from tissue injury), neuropathic (from nerve injury), or nociplastic (from a sensitised nervous system), all of which affect work-up and treatment decisions at every level; however, in practice there is considerable overlap in the different types of pain mechanisms within and between patients, so many experts consider pain classification as a continuum. The biopsychosocial model of pain presents physical symptoms as the denouement of a dynamic interaction between biological, psychological, and social factors. Although it is widely known that pain can cause psychological distress and sleep problems, many medical practitioners do not realise that these associations are bidirectional. While predisposing factors and consequences of chronic pain are well known, the flipside is that factors promoting resilience, such as emotional support systems and good health, can promote healing and reduce pain chronification. Quality of life indicators and neuroplastic changes might also be reversible with adequate pain management. Clinical trials and guidelines typically recommend a personalised multimodal, interdisciplinary treatment approach, which might include pharmacotherapy, psychotherapy, integrative treatments, and invasive procedures.
To read this article in full you will need to make a payment
Cohen M
et al.
The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises.
Pain. 2020; (published online May 23.)
Why patients visit their doctors: assessing the most prevalent conditions in a defined American population.
Mayo Clin Proc. 2013; 88: 56-67
The state of US health, 1990–2010: burden of diseases, injuries, and risk factors.
JAMA. 2013; 310: 591-608
Prevalence of chronic pain and high-impact chronic pain among adults - United States, 2016.
MMWR Morb Mortal Wkly Rep. 2018; 67: 1001-1006
Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies.
BMJ Open. 2016; 6e010364
The course of chronic pain in the community: results of a 4-year follow-up study.
Pain. 2002; 99: 299-307
Nociplastic pain: towards an understanding of prevalent pain conditions.
Lancet. 2021; 397: 2098-2110
Chronic pain: a review of its epidemiology and associated factors in population-based studies.
Br J Anaesth. 2019; 123: e273-e283
Buscemi J
Ferguson MJ
The future of pain research, education, and treatment: a summary of the IOM report “Relieving pain in America: a blueprint for transforming prevention, care, education, and research”.
Transl Behav Med. 2012; 2: 6-8
11.
GBD 2016 Disease and Injury Incidence and Prevalence Collaborators
Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
Lancet. 2017; 390: 1211-1259
Reframing chronic pain as a disease, not a symptom: rationale and implications for pain management.
Postgrad Med. 2019; 131: 185-198
Barke A
et al.
Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11).
Pain. 2019; 160: 19-27
Gray matter alterations in chronic pain: a network-oriented meta-analytic approach.
Neuroimage Clin. 2014; 4: 676-686
Effective treatment of chronic low back pain in humans reverses abnormal brain anatomy and function.
J Neurosci. 2011; 31: 7540-7550
Evaluating psychosocial contributions to chronic pain outcomes.
Prog Neuropsychopharmacol Biol Psychiatry. 2018; 87: 168-182
The role of psychosocial processes in the development and maintenance of chronic pain.
J Pain. 2016; 17: T70-T92
Biopsychosocial factors associated with non-recovery after a minor transport-related injury: a systematic review.
PLoS One. 2018; 13e0198352
The nature and prevalence of chronic pain in homeless persons: an observational study.
F1000 Res. 2013; 2: 164
Tieu L
et al.
Characteristics and factors associated with pain in older homeless individuals: results from the health outcomes in people experiencing homelessness in older middle age (HOPE HOME) study.
J Pain. 2017; 18: 1036-1045
Turk DC
Dobscha SK
Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder.
Pain. 2011; 152: 488-497
Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links.
Psychol Med. 2006; 36: 575-586
Chronic pain, associated factors, and impact on daily life: are there differences between the sexes?.
Cad Saude Publica. 2012; 28: 1459-1467
Chronic pain and mortality: a systematic review.
PLoS One. 2014; 9e99048
Mauer M
et al.
Baseline quality of life as a prognostic indicator of survival: a meta-analysis of individual patient data from EORTC clinical trials.
Lancet Oncol. 2009; 10: 865-871
Chronic postsurgical pain: current evidence for prevention and management.
Korean J Pain. 2018; 31: 155-173
Postoperative pain-from mechanisms to treatment.
Pain Rep. 2017; 2: e588
Neuropathic pain: mechanisms and their clinical implications.
BMJ. 2014; 348f7656
Inflammatory pain hypersensitivity mediated by phenotypic switch in myelinated primary sensory neurons.
Nature. 1996; 384: 360-364
The immune-suppressive effects of pain.
Adv Exp Med Biol. 2003; 521: 117-125
Ruether W
May A
Brain gray matter decrease in chronic pain is the consequence and not the cause of pain.
J Neurosci. 2009; 29: 13746-13750
Mirror therapy for phantom limb pain: brain changes and the role of body representation.
Eur J Pain. 2014; 18: 729-739
Owens DK
Shekelle P
Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians.
Ann Intern Med. 2011; 154: 181-189
Concialdi K
et al.
The prevalence of probable neuropathic pain in the US: results from a multimodal general-population health survey.
J Pain Res. 2017; 10: 2525-2538
Neuropathic pain: an updated grading system for research and clinical practice.
Pain. 2016; 157: 1599-1606
Classification and treatment of chronic neck pain: a longitudinal cohort study.
Reg Anesth Pain Med. 2017; 42: 52-61
Fernández-de-las-Peñas C
Arroyo-Morales M
The contribution of previous episodes of pain, pain intensity, physical impairment, and pain-related fear to disability in patients with chronic mechanical neck pain.
Am J Phys Med Rehabil. 2012; 91: 1070-1076
Howard M
Thacker M
Distinguishing between nociceptive and neuropathic components in chronic low back pain using behavioural evaluation and sensory examination.
Musculoskelet Sci Pract. 2017; 27: 40-48
Saracoglu M
Erdem HR
The effects of coexisting fibromyalgia syndrome on pain intensity, disability, and treatment outcome in patients with chronic lateral epicondylitis.
Pain Med. 2012; 13: 270-280
Current understanding of the mixed pain concept: a brief narrative review.
Curr Med Res Opin. 2019; 35: 1011-1018
Leal A
Esquivias A
Mixed pain can be discerned in the primary care and orthopedics settings in Spain: a large cross-sectional study.
Clin J Pain. 2017; 33: 1100-1108
Effect of 1.5% topical diclofenac on clinical neuropathic pain.
Anesthesiology. 2015; 123: 191-198
Persistent postsurgical pain: pathophysiology and preventative pharmacologic considerations.
Anesthesiology. 2018; 129: 590-607
CDC guideline for prescribing opioids for chronic pain - United States, 2016.
MMWR Recomm Rep. 2016; 65: 1-49
Department of Health & Human Services
Letter to Physicians for Responsible Opioid Prescribing (PROP), docket # FDA-2012-P-0818.
Terminology of chronic pain: the need to “level the playing field”.
J Pain Res. 2016; 9: 23-24
Sensory, motivational, and central control determinants of pain: a new conceptual model in pain.
in: Kenshalo DRJ The skin senses: proceedings. Charles C. Thomas, Springfield, Illinois1968: 423-443
Management of chronic pain in cancer survivors.
Cancer J. 2008; 14: 401-409
Psychological aspects of chronic musculoskeletal pain.
Best Pract Res Clin Rheumatol. 2015; 29: 147-155
Hochberg MC
et al.
2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee.
Arthritis Rheumatol. 2020; 72: 220-233
Towards a mechanism-based classification of pain?.
Pain. 1998; 77: 227-229
US Department of Health and Human Services
Pain Management Best Practices Inter-Agency Task Force report: updates, gaps, inconsistencies, and recommendations.
Interdisciplinary chronic pain management: past, present, and future.
Am Psychol. 2014; 69: 119-130
Advancing the pain agenda in the veteran population.
Anesthesiol Clin. 2016; 34: 357-378
58.
NICE
Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain.
Physical activity and exercise for chronic pain in adults: an overview of Cochrane reviews.
Cochrane Database Syst Rev. 2017; 4CD011279
Toward exercise as personalized medicine.
Sports Med. 2013; 43: 157-165
Psychological therapies for the management of chronic pain (excluding headache) in adults.
Cochrane Database Syst Rev. 2012; 11CD007407
Acceptance and commitment therapy (ACT) for chronic pain: a systematic review and meta-analyses.
Clin J Pain. 2017; 33: 552-568
Mindfulness meditation for chronic pain: systematic review and meta-analysis.
Ann Behav Med. 2017; 51: 199-213
Efficacy of biofeedback in chronic back pain: a meta-analysis.
Int J Behav Med. 2017; 24: 25-41
Yoga treatment for chronic non-specific low back pain.
Cochrane Database Syst Rev. 2017; 1CD010671
Effectiveness of Tai Chi for chronic musculoskeletal pain conditions: updated systematic review and meta-analysis.
Phys Ther. 2017; 97: 227-238
Acupuncture for the relief of chronic pain: a synthesis of systematic reviews.
Medicina (Kaunas). 2019; 56: 6
Acupuncture for chronic pain: update of an individual patient data meta-analysis.
J Pain. 2018; 19: 455-474
Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis.
Spine J. 2018; 18: 866-879
Vernon H
et al.
Manipulation and mobilization for treating chronic nonspecific neck pain: a systematic review and meta-analysis for an appropriateness panel.
Pain Physician. 2019; 22: E55-E70
Dietary supplements for treating osteoarthritis: a systematic review and meta-analysis.
Br J Sports Med. 2018; 52: 167-175
Music-induced analgesia in chronic pain conditions: a systematic review and meta-analysis.
Pain Physician. 2017; 20: 597-610
Transcutaneous electrical nerve stimulation (TENS) for chronic pain - an overview of Cochrane Reviews.
Cochrane Database Syst Rev. 2019; 4CD011890
Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis.
Lancet Neurol. 2015; 14: 162-173
Topical capsaicin (high concentration) for chronic neuropathic pain in adults.
Cochrane Database Syst Rev. 2017; 1CD007393
Topical lidocaine for neuropathic pain in adults.
Cochrane Database Syst Rev. 2014; 2014CD010958
Compounded topical pain creams to treat localized chronic pain: a randomized controlled trial.
Ann Intern Med. 2019; 170: 309-318
Tam CK
et al.
Evidence-based recommendations on the pharmacological management of osteoarthritis and chronic low back pain: an Asian consensus.
Asian J Anesthesiol. 2019; 57: 37-54
Ferreira PH
et al.
Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials.
BMJ. 2015; 350h1225
Friedly J
et al.
Systemic pharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline.
Ann Intern Med. 2017; 166: 480-492
Stoneburner A
et al.
Correlates of benzodiazepine use and adverse outcomes among patients with chronic pain prescribed long-term opioid therapy.
Pain Med. 2019; 20: 1148-1155
EULAR revised recommendations for the management of fibromyalgia.
Ann Rheum Dis. 2017; 76: 318-328
The role of descending inhibitory pathways on chronic pain modulation and clinical implications.
Pain Pract. 2014; 14: 656-667
New persistent opioid use after minor and major surgical procedures in US adults.
JAMA Surg. 2017; 152e170504
Wilson SM
Spevak C
Opioid therapy for chronic pain: overview of the 2017 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline.
Pain Med. 2018; 19: 928-941
Opioids for chronic noncancer pain: a systematic review and meta-analysis.
JAMA. 2018; 320: 2448-2460
Opioid use in fibromyalgia: a cautionary tale.
Mayo Clin Proc. 2016; 91: 640-648
The efficacy of pharmacologic treatment of temporomandibular disorders.
Oral Maxillofac Surg Clin North Am. 2018; 30: 279-285
What is new in Rome IV.
J Neurogastroenterol Motil. 2017; 23: 151-163
Low-dose naltrexone (LDN)-review of therapeutic utilization.
Med Sci (Basel). 2018; 6: 6
Health-related quality of life in patients receiving long-term opioid therapy: a systematic review with meta-analysis.
Qual Life Res. 2017; 26: 1955-1967
The effectiveness and risks of long-term opioid treatment of chronic pain.
Evid Rep Technol Assess (Full Rep). 2014; 218: 1-219
Leatherman S
et al.
Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy.
JAMA Intern Med. 2015; 175: 608-615
Out-of-hospital mortality among patients receiving methadone for noncancer pain.
JAMA Intern Med. 2015; 175: 420-427
Chronic pain and opioid misuse: a review of reviews.
Subst Abuse Treat Prev Policy. 2017; 12: 36
Ney JP
van der Goes DN
Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis.
Pain. 2015; 156: 569-576
Opioid abuse in chronic pain—misconceptions and mitigation strategies.
N Engl J Med. 2016; 374: 1253-1263
Fairbairn N
et al.
Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: a systematic review.
JAMA Netw Open. 2019; 2e193365
Balancing the risks and benefits of opioid therapy: the pill and the pendulum.
Mayo Clin Proc. 2019; 94: 2385-2389
A review of potential adverse effects of long-term opioid therapy: a practitioner's guide.
Prim Care Companion CNS Disord. 2012; 14: 14
Semenov Y
et al.
Epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain: a multicenter, randomized, comparative-effectiveness study.
Anesthesiology. 2014; 121: 1045-1055
Harvey WF
et al.
Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial.
JAMA. 2017; 317: 1967-1975
Epidural corticosteroid injections for sciatica: a Cochrane review with meta-analysis.
Cochrane Database Syst Rev. 2020; 4CD013577
Epidural injections for lumbar radiculopathy and spinal stenosis: a comparative systematic review and meta-analysis.
Pain Physician. 2016; 19: E365-E410
Epidural steroids: a comprehensive, evidence-based review.
Reg Anesth Pain Med. 2013; 38: 175-200
Candido KD
et al.
Do cervical epidural injections provide long-term relief in neck and upper extremity pain? A systematic review.
Pain Physician. 2015; 18: 39-60
Park SJ
et al.
Comparison of clinical efficacy between transforaminal and interlaminar epidural injections in lumbosacral disc herniation: a systematic review and meta-analysis.
Pain Physician. 2018; 21: 433-448
King W
Kennedy DJ
The effectiveness and risks of fluoroscopically-guided cervical medial branch thermal radiofrequency neurotomy: a systematic review with comprehensive analysis of the published data.
Pain Med. 2016; 17: 658-669
Gonzalez Cota A
Bogduk N
Systematic review of the effectiveness of lumbar medial branch thermal radiofrequency neurotomy, stratified for diagnostic methods and procedural technique.
Pain Med. 2020; 21: 1122-1141
Bhatia A
et al.
Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group.
Reg Anesth Pain Med. 2020; 45: 424-467
Ostelo RWJG
et al.
Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: the mint randomized clinical trials.
JAMA. 2017; 318: 68-81
Chronic postsurgical pain in Europe: an observational study.
Eur J Anaesthesiol. 2015; 32: 725-734
Persistent pain after joint replacement: prevalence, sensory qualities, and postoperative determinants.
Pain. 2011; 152: 566-572
Ang DC
et al.
Pain coping skills training for patients who catastrophize about pain prior to knee arthroplasty: a multisite randomized clinical trial.
J Bone Joint Surg Am. 2019; 101: 218-227
Surgical versus non-operative treatment for lumbar disc herniation: a systematic review and meta-analysis.
Clin Rehabil. 2018; 32: 146-160
Gokaslan AK
Bydon A
Lumbar fusion versus nonoperative management for treatment of discogenic low back pain: a systematic review and meta-analysis of randomized controlled trials.
J Spinal Disord Tech. 2014; 27: 297-304
Owens DK
et al.
Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society.
Spine. 2009; 34: 1066-1077
Surgical versus non-surgical treatment for lumbar spinal stenosis.
Cochrane Database Syst Rev. 2016; 2016CD010264
Surgery versus conservative care for neck pain: a systematic review.
Eur Spine J. 2013; 22: 87-95
Nonoperative versus operative management for the treatment degenerative cervical myelopathy: an updated systematic review.
Global Spine J. 2017; 7: 35-41S
van Zwet E
et al.
The NECK trial: effectiveness of anterior cervical discectomy with or without interbody fusion and arthroplasty in the treatment of cervical disc herniation; a double-blinded randomized controlled trial.
Spine J. 2019; 19: 965-975
McNicol E
et al.
Systematic review and meta-analysis of placebo/sham controlled randomised trials of spinal cord stimulation for neuropathic pain.
Pain. 2020; 161: 24-35
Moeschler SM
et al.
The effect of spinal cord stimulation on pain medication reduction in intractable spine and limb pain: a systematic review of randomized controlled trials and meta-analysis.
J Pain Res. 2019; 12: 1311-1324
Bendel MA
Murad MH
Spinal stimulation for the treatment of intractable spine and limb pain: a systematic review of RCTs and meta-analysis.
Mayo Clin Proc. 2019; 94: 1475-1487
The polyanalgesic consensus conference (PACC): recommendations on intrathecal drug infusion systems best practices and guidelines.
Neuromodulation. 2017; 20: 96-132
Complementary and alternative medicine use among adults and children: United States, 2007.
Natl Health Stat Report. 2008; 12: 1-23
Chen H
Ceballos R
Acupuncture use among American adults: what acupuncture practitioners can learn from National Health Interview Survey 2007?.
Evid Based Complement Alternat Med. 2012; 2012710750
Sham device v inert pill: randomised controlled trial of two placebo treatments.
BMJ. 2006; 332: 391-397
Brown 4th, CH
Cohen SP
Epidural injections for spinal pain: a systematic review and meta-analysis evaluating the “control” injections in randomized controlled trials.
Anesthesiology. 2013; 119: 907-931
Unique aspects of clinical trials of invasive therapies for chronic pain.
Pain Rep. 2018; 4: e687
Atluri S
et al.
Do regenerative medicine therapies provide long-term relief in chronic low back pain: a systematic review and metaanalysis.
Pain Physician. 2018; 21: 515-540
Chapman CR
Vierck CJ
The transition of acute postoperative pain to chronic pain: an integrative overview of research on mechanisms.
J Pain. 2017; 18 (359.38): 359.e1
Necka EA
Atlas LY
Distinguishing pain from nociception, salience, and arousal: how autonomic nervous system activity can improve neuroimaging tests of specificity.
Neuroimage. 2020; 204116254
Ljungqvist O
Gustafsson UO
Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines.
BJS Open. 2020; 4: 157-163
Epigenetic mechanisms of chronic pain.
Trends Neurosci. 2015; 38: 237-246
Neuroimaging of pain: human evidence and clinical relevance of central nervous system processes and modulation.
Anesthesiology. 2018; 128: 1241-1254

Images Powered by Shutterstock