title: Pharmacotherapy of chronic pain: a synthesis of recommendations from systematic reviews.
abstract: OBJECTIVE
  Chronic pain is one of the most prevalent, costly and disabling conditions in both clinical practice and the workplace, yet often remains inadequately treated. Moreover, chronic pain commonly co-occurs with depression, anxiety and somatoform disorders, and adversely affects response of these conditions to psychiatric treatments. This article provides an evidence-based approach to the pharmacotherapy of chronic pain.
  
  
  METHODS
  This narrative review is derived largely from meta-analyses and systematic reviews published since 2005. For a few medications, findings from multiple recent trials are synthesized if a systematic review had not yet been published. Classes of medications are first reviewed, followed by an overview of four common pain disorders: neuropathic pain, low back pain, fibromyalgia and osteoarthritis.
  
  
  RESULTS
  A stepped care approach based upon existing evidence includes (1) simple analgesics (acetaminophen or nonsteroidal anti-inflammatory drugs); (2) tricyclic antidepressants (if neuropathic, back or fibromyalgia pain) or tramadol; (3) gabapentin, duloxetine or pregabalin if neuropathic pain; (4) cyclobenzaprine, pregabalin, duloxetine, or milnacipran for fibromyalgia; (5) topical analgesics (capsaicin, lidocaine, salicylates) if localized neuropathic or arthritic pain; and (6) opioids. Disease-specific recommendations for neuropathic, low back, fibromyalgia and osteoarthritis pain are reviewed.
  
  
  CONCLUSIONS
  A number of medications have proven effective in chronic pain disorders and their use individually or in combination should improve the management of chronic pain.
authors.affiliation: Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA. kkroenke@regenstrief.org
authors.forename: Kurt
authors.initials: K
authors.lastname: Kroenke
authors.forename: Erin E
authors.initials: EE
authors.lastname: Krebs
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Bair
mesh_terms: D000082:Acetaminophen / Q000627:therapeutic use*; D000588:Amines / Q000627:therapeutic use*; D000700:Analgesics / Q000627:therapeutic use*; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use*; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use*; D001008:Anxiety Disorders / Q000453:epidemiology; D001241:Aspirin / Q000627:therapeutic use*; D002908:Chronic Disease; D003509:Cyclohexanecarboxylic Acids / Q000627:therapeutic use*; D003866:Depressive Disorder / Q000453:epidemiology; D000077206:Gabapentin; D017408:Guidelines as Topic; D006801:Humans; D010146:Pain / Q000188:drug therapy* / Q000453:epidemiology; D013001:Somatoform Disorders / Q000453:epidemiology; D014147:Tramadol / Q000627:therapeutic use*; D005680:gamma-Aminobutyric Acid / Q000627:therapeutic use*
chemical_list: D000588:Amines; D000700:Analgesics; D000701:Analgesics, Opioid; D000893:Anti-Inflammatory Agents; D000894:Anti-Inflammatory Agents, Non-Steroidal; D003509:Cyclohexanecarboxylic Acids; D000082:Acetaminophen; D014147:Tramadol; D005680:gamma-Aminobutyric Acid; D000077206:Gabapentin; D001241:Aspirin