Chronic pain toolkit for family physicians
Chronic pain management calls for balanced, patient-centered care guided by evidence.
Chronic pain represents a substantial public health issue with tremendous economic, social and medical costs. As the percentage of the U.S. population using opioid analgesics for pain control grows, so do the rates of abuse, misuse and overdose of these drugs.
As a first point of contact for patients with chronic pain, you play a vital role in balancing pain management needs with the risk of drug misuse. Treatment may include subspecialists, but as the coordinator and manager of care for the majority of these patients, you can customize treatment to each patient’s situation after reviewing potential risks, benefits, side effects and functional assessments, and monitor ongoing therapy.
The evidence-based resources on this page will empower you to address chronic pain management through advocacy, collaboration and education.
Guidelines and recommendations
Find key clinical guidelines and recommendations to support safe, evidence-based care for patients living with chronic pain.
Clinical practice guidelines
(Affirmation of Value, June 2023)
The 2022 CDC Guideline for Prescribing Opioids for Pain was developed by the Centers for Disease Control and Prevention and was reviewed and categorized as Affirmation of Value by the American Academy of Family Physicians.
Key Recommendations
- Nonpharmacologic and nonopioid pharmacologic therapies are preferred for chronic pain. Opioid therapy should be considered only when benefits for both pain and function are anticipated to outweigh the risks. If opioids are used, they should be combined with nonpharmacologic and nonopioid pharmacologic therapy as appropriate.
- Realistic treatment goals for pain and function should be established before initiation of opioid therapy. Opioid treatment should be continued only if there is meaningful improvement in pain and function that outweighs risk.
- When starting opioid therapy for chronic pain, the lowest effective dose of immediate-release opioids should be prescribed instead of extended-release/long-active (ER/LA) opioids.
- Benefits and risks should be reassessed when increasing dosages to ≥50 morphine milligram equivalents (MME)/day. Dosages ≥90 MME/day should be carefully justified or avoided if possible.
- For acute pain, the lowest effective dose of immediate-release opioids should be prescribed in no greater quantity than is needed for severe pain.
- Benefits and harms should be evaluated with patients within one to four weeks of initiating or escalating dose of opioids for chronic pain and at least every three months thereafter. If benefits do not outweigh the harms, a plan to taper opioids and optimize other therapies should be developed.
- Risk factors for opioid-related harms should be evaluated prior to initiation and periodically during treatment. Strategies to mitigate risk should be developed, including offering naloxone to those at increased risk for overdose.
- A patient’s history of controlled substance prescriptions using a prescription drug monitoring program (PDMP). PDMP data should be reviewed when starting opioid therapy and periodically during treatment.
- Urine drug testing may be used prior to initiating opioid therapy and periodically during treatment to assess for controlled prescription medications as well as illicit drugs.
- Co-prescription of opioids and benzodiazepines should be avoided whenever possible.
- Evidence-based treatment including medication-assisted treatment with buprenorphine or methadone and behavioral therapies should be offered to patients with opioid use disorder.
Management of Acute Pain from Non-Low Back, Musculoskeletal Injuries in Adults
(Jointly Developed, August 2020)
The guideline was developed by the American College of Physicians and the American Academy of Family Physicians.
Key Recommendations
- Topical NSAIDs, with or without menthol gel, should be used as first line therapy for adults with acute pain from non-low back, musculoskeletal injuries.
- Oral NSAIDs and acetaminophen may be considered as options for pharmacologic treatment for adults with acute pain from non-low back, musculoskeletal injuries. Non-pharmacologic options for patients include specific acupressure or transcutaneous electrical nerve stimulation (TENS).
- Opioids, including tramadol, should not be used as first line treatments for adults with acute pain from non-low back musculoskeletal injuries. Severity of the injury and patient intolerance of other treatments, and potential harms should be considered before initiating treatment with opioids.
Practice-based resources
Chronic pain assessment and inventory (PDF) – Primary care solution to assist in the effective assessment, diagnosis, and management of chronic pain
Treating Opioid Use Disorder as a Chronic Condition (PDF) – Guidance for incorporating evidence-based treatments and opioid SBIRT into primary care practice.
FDA Warning: Use of Buprenorphine to Treat Opioid Use Disorder and Pain Causes Dental Problems – This is an FDA-required warning providing background and recommendations around dental problems have been reported with medicines containing buprenorphine that are dissolved in the mouth.
Conversation starters: If you have chronic pain – Patient-facing resource on chronic pain that answers questions about treatment options that don't involve opioids, what to expect when they are prescribed opioids to reduce pain and what else they can do to manage chronic pain.
Nonopioid therapy conversation starter – Talking points for clinicians to use when encouraging nonopioid therapies.
Clinical reference tool for nonopioid therapies for pain – Reference guide to help clinicians understand recommendations to utilize nonopioid therapies for pain
Community engagement
These resources highlight community-level initiatives and directories that advance prevention, early intervention and coordinated response to opioid misuse.
Opioid use and misuse: a public health concern (position paper) – Addresses the dual public health crises of undertreated pain and opioid misuse/abuse at both the national and grassroots levels.
North American Syringe Exchange Network (NASEN) – Nonprofit organization supporting syringe services programs (SSPs) working to ensure people who use drugs receive the highest quality care, tools and support available.
Overdose Resource Exchange – Central collection of communication materials and educational resources about opioid misuse, addiction, treatment and overdose prevention.
Advocacy
These advocacy resources outline the AAFP’s policy perspectives and priorities on substance use disorders, naloxone access and public health approaches to opioid misuse.
Patient education
The AAFP patient education website FamilyDoctor.org provides many patient-facing resources.