Chronic pain


Defined as pain that lasts longer than 3-6 months or lasting 1 month longer than the usual time for an injury to heal.

One of the most common conditions encountered by healthcare professionals, particularly those 65 years and older.

Approximately 25.3 million US adults, or 11.2% of the population, have chronic daily pain.


Nearly 40 million adults (17.6 percent) have severe pain.

Approximately 20% of the population has chronic pain as defined by pain on most days for the past six months. 

In 2016 an estimated 50 million adults in the US were living with chronic noncancer pain, many of whom were prescribed opioid medication.

Chronic pain is one of the most common reasons for opioid prescriptions.

Chronic pain contributes to a financial burden of $635 billion each year from costs of medical care, loss of productivity, and disability programs.

The prevalence of chronic pain among older adults is more than 40%.

Chronic pain affects up to 60% of people older than 65 years.

Older adults with chronic pain are frequently unable to perform activities of basic living or maintain independent living, and have less mobility, poor cognitive function, and a higher level of disability.
It is associated with several clinical conditions, such as headache, neuralgia, and fibromyalgia, without clear tissue pathology.
It may be a symptom of irreversible disease.

10% of patients have debilitating pain

Estimated 3 to 4% of adults with daily pain use opioids long-term to manage chronic pain.

In older people chronic pain leads to reduce physical activity, increases the frailty syndrome, increases falls, increases physical disability, and increases cognitive impairment.

The use of opioids in chronic pain are uncertain, where as the harms associated with opioids include diversion, addiction, overdose, and death.

Most patients who are prescribed opioids for the treatment of chronic noncancer pain will not benefit from those drugs.

Long-term opioid administration is only minimally effective on chronic pain and is associated with tolerance, drowsiness, dependence, impaired memory, impaired concentration, and impaired judgment.

Chronic pain can be affected by neuropsychological factors, and is common in many patients.

Prolonged and repeated episodes of nociceptive pain result in neural changes that enhance pain sensitivity, heighten pain anticipation, and aversion, and cause synaptic networks involved in emotion and cognition to prior the  painful stimuli over pleasurable ones.

The chronic pain experience of prolonged pain at sites that may have been previously injured, yet are otherwise currently well is related to neuroplasticity due to a maladaptive reorganization of the nervous system, both peripherally and centrally. 

During the period of tissue injury, noxious stimuli and inflammation from the damage cause an increase in nociceptive input from the periphery to the central nervous system. 

The prolonged nociception input from the periphery elicits a neuroplastic response at the cortical level to change its somatotopic organization for the painful site, inducing central sensitization.

Emotional trauma associated with pain experience on  a single location can enhance negative emotions during future episodes.

American Pain Society estimates that 50 million Americans are partially or totally disabled by chronic pain.

Estimated 126 million Americans have chronic pain, and with the aging population, that number is expected to rise.

Approximately 3-4% of the US population are prescribed long-term opioid therapy for chronic pain.

Occurs in more than 30% of US population.

Depression, anxiety and substance abuse disorders are common with chronic pain conditions and are frequently encountered.

There is a bidirectional relationship between chronic pain and mental health disorders.

Patient with chronic pain may have depression and anxiety and pain castrophizing with overly negative thoughts about pain with tendency to feel helpless and a magnification of the threat of pain and the increased likelihood the pain will interfere with daily activities.

Patients with chronic pain often do not respond to medication, and leads to over prescribing and the opioid crisis.

Annual cost estimated between 560 and $635 billion in the US alone.

Almost 90% of patients with chronic pain have experienced pain for at least one year and more than 85% of individuals experience pain at least 2-3 times per week.

Incidence increasing due to increasing age of population, and rising prevalence of chronic conditions, such as obesity and diabetes.

Associated with increased primary care visits, hospitalizations, and emergency department visits, and is associated with increased overall health care costs.

Affects more people than diabetes, cancer, and heart disease combined.

Is the major reason people visit their primary care physicians.

Primary care physicians are often the very first care takers for patients with chronic pain, treating 52% of such patients.

Patients with chronic pain should be routinely questioned about the presence of suicidality and the history of sexual violence.

Musculoskeletal pain, particularly joint and back pain, is the most common cause of chronic pain with more than 28% of the US adults reporting low back pain.

Most patients experience locolregional pain, referring to pain syndromes anatomically limited to a sensory field of one or only a few peripheral or spinal nerves.

Locoregional muscular skeletal pain is leading presentation of chronic pain in the US.

Other causes of chronic pain include: Almost 20% knee pain,, headaches or migraines 16%, neck pain 15%, shoulder pain 9%, finger pain 7.6% and hip pain 7.1%.

Prevalence higher among women.

Women are more likely to develop greater pain severity, and to develop other chronic pain conditions including chronic fatigue syndrome, endometriosis, fibromyalgia, vulvodynia, and interstitial cystitis.

Chronic pain more common with increasing age and lower socioeconomic status.

Chronic pain affects a significant portion of older individuals and it’s associated with numerous other conditions, including frailty, debility, and depression.

Mexican Americans have lower rates of chronic pain.

African-Americans have higher levels of clinical pain and have lower pain tolerance based on clinical studies.

Interferes with sleep, work, daily activities, social activities, and overall quality of life.

Alters mood, appetite, energy, and sexual activity.

Chronic pain and mental health disorders are common and suggest that a bidirectional relationship exists between the two processes.

Patients with chronic pain are at risk for depression, anxiety, substance abuse disorders, suicide, smoking abuse, and many have experienced sexual violence.

One in five adults who suffer from chronic pain have suicidal ideation, and 8 percent to 41% of those adults attempted suicide at least once (Racine M).

Pain causes alterations in the neurocircuitry related to reward, resulting in vulnerability to suicide and to riskier use of opioids.

Chronic pain is linked to suicide, and is associated with opioid overdose.

Chronic pain associated with sleep difficulties and increases an individual’s risk for developing insomnia.

30 to 50% of patients suffering from chronic pain also reported insomnia, and 53% of such patients require medical attention for their sleep dysfunction.

Individuals who suffer from chronic pain for more than 3 months have a higher ideation of suicide.

Concomitant chronic pain and mental health disorders complicate drug management.

Chronic pain prevalence ranges from 2-40% and the prevalence of mental health disorders range from 17-29%.

Chronic administration of opioids results in a an increase in levels of circulating inflammatory cytokines such as interleukin 6 (IL6), interleukin 1B (IL1B), and tumor necrosis factor (TNF).

The increase in these cytokines results in hyperalgesia and increased pain.

One quarter of Americans suffer from low back or neck pain, nearly 1 in 5 suffers from knee pain, and more than 15% experience chronic headache almost 1 in 10 report shoulder, finger, or hip pain.

Associated disability so that nearly 1/3 of patients with low back pain, knee pain, neck pain, or headaches are not able to perform basic activities of daily living due to their pain.

It is leading cause of years lived with disability in people age 50 years and older.

Affects individuals of all ages, with prevalence increasing with age.

Estimated cost of $635 billion a year for medical treatment and lost productivity.

Most common cause of disability.

Sixty percent of individuals age 65 and older experience chronic pain lasting one year or longer.

Frequently complicated by CNS changes of central sensitization and microglia activation.

Frequently accompanied by mental health disorders complicating it’s care.

Has deleterious effect on quality of life and daily functions.

Microglia discharge cytokines, prostanoids, and free radicals which sensitize the CNS to pain transmitting neurons.

Dorsal horn sensitization a neurophysiologic phenomenon in acute and chronic pain manifesting in secondary hyperalgesia or allodynia.

One in three people in the U.S. suffer from chronic pain during their lifetime.

Widespread chronic idiopathic pain occurs in about 10% of the population.

Major cause of lost productivity, human suffering and extensive healthcare costs.

Goals of management is to achieve the greatest level of pain reduction and functional improvement with minimal adverse effects.
The goal of management of chronic pain is for functional restoration, improving the quality of life, and avoiding permanent disability.

Consideration is given to the level of pain reduction that will improve preserve physical function and quality of life.

Treatments include aspirin, acetaminophen, non-steroidal inflammatory drugs, antidepressants, anticonvulsants, and opioid analgesics.

Chronic pain significantly reduce the volume of grey matter in the brain globally, and more specifically at the prefrontal cortex and right thalamus.

Following treatment, these abnormalities in cortical reorganization and grey matter volume are resolved, as well as their symptoms: Similar findings reported for phantom limb pain, chronic low back pain and carpal tunnel syndrome.

Treatment of chronic pain requires a multimodal approach with nonpharmacologic and pharmacologic strategies.

5-8 million Americans use opioids for chronic pain.

Trials of opioid therapy results only in an approximate 30% reduction in chronic pain scores.

Patients with chronic pain who have incorporated aerobic exercise, muscle strengthening, or movement therapy have had improved strength, mobility, balance, and less depression and anxiety.

Inadequate self-efficacy is a barrier to increasing physical activity and reducing sedentary time in patients with chronic pain.

Medical therapy for neuropathic pain with existing pharmacological treatments are limited with more than 40-60% of patients obtaining partial relief of their pain.

Roughly half of all patients with common painful conditions such as diabetic peripheral,neuropathy, postherpetic neuralgia, complex regional pain syndrome, failed back surgery syndrome with a neuropathoc component, and chronic radiculopathy, such a sciatica, will not have sufficient improvement with conservative pain care measures.

A ssociated with suicidality.

Patients  with severe pain have worse health, used more health care, and have more disability than those with less severe pain.

Chronic pain is an epidemic in older adults with 52.8% of patients reporting pain that interfered with activities of daily living in the previous month.

Opioid prescribing for chronic pain:

Nonpharmacologic therapy and non-opioid pharmacologic therapy is preferred for chronic pain. 

Complementary health approaches that have been studied for pain:



Massage therapy




Relaxation techniques


Spinal manipulation


Tai chi and qi gong




Certain chronic pain conditions may occur together; chronic fatigue syndrome, endometriosis, fibromyalgia, interstitial cystitis, irritable bowel syndrome, temporomandibular joint dysfunction, and  vulvar pain.

Medical management should consist of medication with the lowest risk of potentially toxic side effects, including antidepressants, anti-convulsants, muscle relaxants, and topical agents.
Acupuncture, biofeedback, cognitive behavior therapy, yoga, and tai chi can reduce the need for medication.

Evidence suggests that some complementary approaches, such as acupuncture, hypnosis, massage, mindfulness meditation, spinal manipulation, tai chi, and yoga, may help to manage some painful conditions.

Opioids should be considered if expected benefits for both pain and function outweigh risks to the patient. 

If opioids are used they should be combined with nonpharmacologic therapy and non-opioid pharmacologic therapy.

Before starting opioid therapy for chronic pain establishment of treatment goals with patients, including goals for pain and function.

Consideration that therapy will be discontinued if benefits do not outweigh risks.

Treatment should continue with opioid therapy only if there is clinically meaningful improvement in pain and function that outweigh risks to patient safety.

Discussions about risks and benefits of opioid therapy and patient and clinical responsibilities for managing therapy must occur.

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