Chronic Pain Management

Diagnostic Criteria

• Chronic pain syndrome is defined as pain persisting beyond 3 months that represents a distinct disease entity characterized by biological, psychological, and social factors rather than merely a symptom of underlying pathology 1
• Minimum screening should include: "How much bodily pain have you had during the last week?" and "Do you have bodily pain that has lasted for more than 3 months?" 1
• Use the ultra-brief PEG tool for rapid assessment in busy clinical settings 2
• Document pain location, quality, severity, temporal patterns, and aggravating/relieving factors 2

Management Strategy

• Chronic pain requires a multimodal, interdisciplinary approach combining non-pharmacological interventions as first-line treatment, with pharmacotherapy tailored to pain mechanism and patient-specific factors 1, 5, 6
• Cognitive Behavioral Therapy (CBT) is strongly recommended for chronic pain management (strong recommendation, moderate quality evidence) 5, 7
• Yoga is strongly recommended for chronic neck/back pain, headache, rheumatoid arthritis, and general musculoskeletal pain (strong recommendation, moderate quality evidence) 5, 7, 8
• Physical and occupational therapy are strongly recommended for chronic pain (strong recommendation, low quality evidence) 5, 7, 8
• Hypnosis is strongly recommended specifically for neuropathic pain (strong recommendation, low quality evidence) 5, 7
• Acetaminophen up to 3 g/day is the safest first-line option, particularly in patients with liver disease, heart problems, or kidney stones 8
• NSAIDs may be used cautiously but should be avoided in patients with cirrhosis (risk of GI bleeding, ascites decompensation, nephrotoxicity) and kidney stones (worsens renal function) 8
• Gabapentin may be considered for neuropathic components with appropriate dose adjustments based on renal function 8
• Opioids should be reserved for moderate-to-severe pain inadequately controlled with non-opioid approaches, and used with extreme caution and lowest effective doses 8
• Patients on methadone for opioid use disorder: split methadone into 6-8 hour doses for continuous pain control (strong recommendation, low quality evidence) 4
• Patients on buprenorphine: increase dosage in divided doses (4-16 mg in 8-hour intervals) as initial step; if inadequate, add long-acting potent opioid or transition to methadone maintenance 4

Interventional Procedures

• Diagnostic and therapeutic interventions should be considered when conservative management fails, including interventional diagnostic procedures and spinal cord stimulation 3
• Intraarticular facet joint injections may be used for symptomatic relief of facet-mediated pain 3
• Ablative techniques should only be considered after other treatment modalities have been attempted 3

Interdisciplinary Team Approach

• HIV medical providers and all chronic pain clinicians should develop and participate in interdisciplinary teams for patients with complex chronic pain, especially those with co-occurring substance use or psychiatric disorders (strong recommendation, very low quality evidence) 1, 2
• Team composition should include primary care providers, physical and occupational therapists, psychologists and psychiatrists, case managers, and pain specialists for consultation when needed 1, 2

Monitoring and Follow-Up

• Establish long-term approach with periodic follow-up evaluations, focusing on functional goals, pain severity reduction, quality of life improvement, and treatment-related adverse events 2
• Regular assessment of liver function, renal function, and cardiac status is essential when using pharmacological treatments 8
• Monitor for signs of aberrant behavior, but maintain nonjudgmental perspective and consider "pseudo-addiction" (medication-seeking behavior due to inadequate pain control) 1

Common Pitfalls and Caveats

• Avoid focusing on unproven interventions, as this delays implementation of evidence-based treatments 6
• Do not treat new pain in patients with existing chronic pain as simply requiring more of the current medication; new pain requires thorough reevaluation 2
• Avoid NSAIDs in cirrhosis patients due to serious complications 8
• Do not neglect screening for unhealthy substance use, as this requires consultation with addiction specialists 1
• Build therapeutic partnership through empathy, reflective listening, and believing patient's pain expression 1
• Set realistic expectations about treatment effectiveness and clarify that goal is functional restoration, not complete pain elimination 1, 2
• Address modifiable psychosocial factors including self-esteem, coping skills, recent losses, mood disorders, and history of violence 4
• Document comprehensive pain assessments and treatment plans clearly in medical records 1