Chronic pain management: pharmacotherapy for chronic pain.

Clinicians should combine nonpharmacologic therapies and pharmacotherapy for management of chronic pain. Safety and effectiveness determine the choice of therapy. Typically, nonopioid analgesics are first-line treatment, including acetaminophen, nonsteroidal anti-inflammatory drugs, and topical drugs. A trial of an opioid, in combination with other modalities, should be considered if pain persists. Because of the potential for serious adverse effects, opioids should be prescribed only if the clinician is familiar with their use and associated risks. If pain is not controlled, consider pharmacogenetic effects or the addition of adjuvant therapy. In states with prescription drug monitoring programs, clinicians must access these programs regularly when prescribing a controlled substance. Consider performing pill counts and random urine drug screening for monitoring drug use. Adjuvant drugs to be considered include antidepressants, buspirone, anticonvulsants, muscle relaxants, onabotulinumtoxinA, clonidine, and corticosteroids, depending on type of pain and individual characteristics.