The pharmacotherapy of chronic pain

Most patients with rheumatic diseases experience difficulties with chronic pain. To assist clinicians in directly addressing this pain, this article presents a treatment approach and algorithm based on best evidence. The usual approach for mild to moderate pain is to start with a nonopioid analgesic. If this is inadequate or poorly tolerated, and if there is an element of sleep loss, it is then reasonable to add an antidepressant with analgesic qualities. If there is a component of neuropathic pain or fibromyalgia, then a trial of one of the gabapentinoids is appropriate. If these steps are inadequate, then an opioid analgesic may be added. For moderate to severe pain, one would initiate a trial of chronic opioid earlier. Cannabinoids and topicals may also be appropriate as single agents or in combination.