Management of chronic non-cancer pain: a framework

Aim: Since publication of the CDC 2016 Guideline, opioid-related mortality in the USA has doubled and a crisis has developed among the 15-20 million Americans with chronic, moderate-to-severe, noncancer pain. Our aim was to develop a comprehensive alternative approach to management of chronic pain. Methods: Analytic review of the clinical literature. Results: Published science provides a solid framework for the management of chronic non-cancer pain, detailed here, even as it leaves many knowledge gaps, which we fill with insights from clinical experience. Conclusion: There is a sufficient basis in science and in clinical experience to achieve adequate control of chronic pain in nearly all patients in a way that adequately balances benefits and potential harms. Plain language summary: Opioid-related mortality in the USA continues to increase rapidly despite the decline in opioid prescriptions achieved by the CDC 2016 Guideline. This Guideline has also created a crisis among the 15-20 million Americans with chronic, moderate-to-severe, noncancer pain. We offer a detailed framework for an alternative approach to management of chronic pain. We also offer some suggestions for solving the problem of illicit drug use, which now accounts for 84% of opioid-related deaths. To the extent possible, we have relied upon published science. However, we also identify many knowledge gaps that we address with insights from clinical experience and thousands of interactions with patients. These knowledge gaps will ultimately need to be addressed by further research.