Implementing AHRQ Effective Health Care Reviews

Helping Clinicians Make Better Treatment Choices

Nonopioid Pharmacologic Treatments for Chronic Pain

 

Am Fam Physician. 2021 May 1;103(9):561-565.

Author disclosure: No relevant financial affiliations.

Key Clinical Issue

What are the effects of nonopioid drugs on pain, function, and quality of life in patients with specific types of chronic pain, and what are the adverse events related to these drugs?

Evidence-Based Answer

People with chronic neuropathic pain and fibromyalgia reported small short-term improvements in pain and function with certain anticonvulsants and moderate short-term improvement with certain antidepressants. (Strength of Recommendation [SOR]: B, based on inconsistent or limited-quality patient-oriented evidence.) Non-steroidal anti-inflammatory drugs (NSAIDs) produced small short-term improvements in pain and function in patients with inflammatory arthritis and osteoarthritis. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) Memantine and serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants were beneficial in the intermediate term for treating fibromyalgia. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) SNRIs were also beneficial for treating low back pain. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) Evidence was insufficient to draw conclusions about long-term effects of any treatments.1

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CLINICAL BOTTOM LINE

Effect of Certain Drugs in Placebo-Controlled and Head-to-Head Trials

ConditionDrugShort-term painIntermediate-term painLong-term painShort-term functionIntermediate-term functionLong-term functionShort-term quality of lifeIntermediate-term quality of life

Antidepressants

Neuropathic pain

Duloxetine vs. placebo

Moderate ● ● ○

No evidence

Small ● ○ ○

No evidence

Small ● ● ○

No evidence

Fibromyalgia

Duloxetine/milnacipran vs. placebo

Small ● ● ○

Small ● ●○

Small ● ● ○

None ● ● ○

Small/none* ● ● ○

Small ● ● ○

Osteoarthritis

Duloxetine vs. placebo

Small ● ● ●

No evidence

Small ● ● ●

No evidence

Small ● ● ●

No evidence

Low back pain

Duloxetine vs. placebo

Small ● ● ○

No evidence

None ● ● ○

No evidence

None ● ● ○

No evidence

Amitriptyline vs. placebo

No evidence

None ● ○ ○

No evidence

None ● ○ ○

No evidence

No evidence

Amitriptyline vs. pregabalin

Small ● ○ ○

No evidence

None ● ○ ○

No evidence

No evidence

No evidence

Anticonvulsants

Neuropathic pain

Pregabalin/gabapentin vs. placebo

Small ● ● ○

None ● ○ ○

None ● ○ ○

Oxcarbazepine vs. placebo

Small ● ● ○

No evidence

None ● ○ ○

Pregabalin vs. gabapentin

Insufficient evidence

No evidence

No evidence

Pregabalin vs. gabapentin enacarbil

None ● ○ ○

None ● ○ ○

None ● ○ ○

Fibromyalgia

Pregabalin/gabapentin vs. placebo

Small ● ● ○

Small ● ● ○

None ● ● ○

NSAIDs

Osteoarthritis

NSAID vs. placebo

Small ● ● ○

No evidence

No evidence

Small ● ● ●

No evidence

No evidence

None ● ● ○

Diclofenac vs. celecoxib

Moderate ● ○ ○

No evidence

No evidence

Moderate ● ○ ○

No evidence

No evidence

No evidence

NSAID vs. NSAID

None ● ○ ○

None ● ○ ○

None ● ○ ○

None ● ○ ○

None ● ○ ○

No evidence

No evidence

Topical diclofenac vs. placebo

Small ● ● ○

No evidence

No evidence

None ● ○ ○

No evidence

No evidence

No evidence

Inflammatory arthritis

NSAID vs. placebo

Small/moderate ● ● ○

Small ● ○ ○

Large ● ○ ○

Small ● ● ○

Small ● ○ ○

None ● ○ ○

Insufficient evidence

Celecoxib vs. diclofenac

None ● ● ○

No evidence

No evidence

None ● ● ○

No evidence

No evidence

No evidence

Celecoxib vs. naproxen

None ● ○ ○

No evidence

No evidence

None ● ○ ○

No evidence

No evidence

None ● ○ ○

Diclofenac vs. meloxicam

None ● ○ ○

No evidence

No evidence

None ● ○ ○

No evidence

No evidence

No evidence

Meloxicam vs. naproxen

No evidence

None ● ○ ○

No evidence

No evidence

No evidence

No evidence

No evidence

Nabumetone vs. naproxen

None ● ○ ○

None ● ○ ○

No evidence

None ● ○ ○

No evidence

No evidence

No evidence

Other drugs

Neuropathic pain

Capsaicin patch

None ● ● ○

No evidence

No evidence

No evidence

No evidence

No evidence

Cannabis

None ● ○ ○

No evidence

None ● ○ ○

No evidence

None ● ○ ○

No evidence

Fibromyalgia

Memantine

No evidence

Moderate ● ○ ○

No evidence

Moderate ● ○ ○

No evidence

Moderate ● ○ ○

Cyclobenzaprine

No evidence

None ● ○ ○

No evidence

Insufficient evidence

No evidence

No evidence

Osteoarthritis

Acetaminophen

None ● ○ ○

None ● ○ ○

None ● ○ ○

None ● ○ ○

No evidence

No evidence


Strength of evidence scale

● ● ● High: Very confident that the effect estimate lies close to the true effect for this outcome. The body of evidence has few or no deficiencies. Findings are stable (i.e., inclusion of additional

Address correspondence to Tyler S. Rogers, MD, at tyler.s.rogers11.mil@mail.mil. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. McDonagh MS, Selph SS, Buckley DI, et al. Nonopioid pharmacologic treatments for chronic pain. Comparative effectiveness review no. 228. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ publication no. 20-EHC010. Rockville, Md.: Agency for Healthcare Research and Quality; April 2020. Accessed June 21, 2020. https://effectivehealthcare.ahrq.gov/sites/default/files/nonopioid-chronic-pain-summary.pdf...

2. Chronic pain. The American Chronic Pain Association. Accessed June 21, 2020. https://www.theacpa.org/conditions-treatments/conditions-a-z/chronic-pain/

3. Bonica JJ. The Management of Pain. Lea and Febiger; 1953.

4. Dowell D, Haegerich TM, Chou R. CDC Guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624–1645.

5. Chakrabarty S, Zoorob R. Fibromyalgia. Am Fam Physician. 2007;76(2):247–254. Accessed February 5, 2021. https://www.aafp.org/afp/2007/0715/p247.html

6. Lindsay TJ, Rodgers BC, Savath V, et al. Treating diabetic peripheral neuropathic pain. Am Fam Physician. 2010;82(2):151–158. Accessed February 5, 2021. https://www.aafp.org/afp/2010/0715/p151.html

7. Ebell MH. Osteoarthritis: rapid evidence review. Am Fam Physician. 2018;97(8):523–526. Accessed February 5, 2021. https://www.aafp.org/afp/2018/0415/p523.html

8. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514–530.

9. American Academy of Family Physicians clinical practice guideline. Diagnosis and treatment of low back pain. April 2017. Accessed June 21, 2020. https://www.aafp.org/patient-care/clinical-recommendations/all/back-pain.html

10. American Academy of Family Physicians. Marijuana and cannabinoids: health, research and regulatory considerations (position paper). July 2019. Accessed June 21, 2020. https://www.aafp.org/about/policies/all/marijuana-cannabinoids.html

11. Wong SSC, Chan WS, Cheung CW. Analgesic effects of cannabinoids for chronic non-cancer pain: a systematic review and meta-analysis with meta-regression. J Neuroimmune Pharmacol. 2020;15(4):801–829.

The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer based on the review. AHRQ's summary is accompanied by an interpretation by an AFP author that will help guide clinicians in making treatment decisions.

For the full review, go to https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/nonopioid-chronic-pain.pdf.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at https://www.aafp.org/afp/ahrq.

 

 

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