Pharmacologic treatment based on type of chronic pain

Type of pain	First-line therapy^*	Considerations for opioid use
Nociceptive	NSAIDs	When other treatment options are inadequate, for pain severe enough to require potentially daily, round-the-clock, long-term treatment. Limit dose and duration whenever possible. Encourage as-needed use linked to meeting specific activity goals.
Neuropathic	Antidepressants (TCAs or SNRIs) or Antiseizure medications
Nociplastic^¶	Antidepressants (TCAs or SNRIs) or Antiseizure medications	Avoid whenever other multidisciplinary treatment options have not been systematically, sufficiently, and consistently trialed. Opioids often worsen nociplastic pain.

For further information refer to UpToDate content on the pharmacologic management of chronic pain and the management of specific chronic pain conditions.

NSAIDS: nonsteroidal antiinflammatory drugs; SNRIs: serotonin-norepinephrine reuptake inhibitors; TCAs: tricyclic antidepressant.

* Initial therapy should be based on the pain condition (if known), patient comorbid conditions, concurrent medications, medication side effect profile, cost, and patient preference regarding dosing frequency.

¶ Central sensitization is now considered a mechanism for nociplastic pain, rather than a clinical diagnosis.

References:

Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. U.S. Department of Health and Human Services. Available at: https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf (August 4, 2022).
Kosek E. The concept of nociplastic pain-where to from here? Pain 2024; 165:S50.

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Pharmacologic treatment based on type of chronic pain