Editing Chronic pain (section)

===Medications===
Various [[Nonopiod analgesics|non-opioid]] medicines are initially recommended to treat chronic pain, depending on whether the pain is due to tissue damage or is [[Peripheral neuropathy|neuropathic]].<ref name="Tauben2015">{{cite journal |vauthors=Tauben D |date=May 2015 |title=Nonopioid medications for pain |journal=Physical Medicine and Rehabilitation Clinics of North America |volume=26 |issue=2 |pages=219–248 |doi=10.1016/j.pmr.2015.01.005 |pmid=25952062}}</ref><ref name="Welsch2015">{{cite journal |vauthors=Welsch P, Sommer C, Schiltenwolf M, Häuser W |date=February 2015 |title=[Opioids in chronic noncancer pain-are opioids superior to nonopioid analgesics? A systematic review and meta-analysis of efficacy, tolerability and safety in randomized head-to-head comparisons of opioids versus nonopioid analgesics of at least four week's duration] |journal=Schmerz |language=de |volume=29 |issue=1 |pages=85–95 |doi=10.1007/s00482-014-1436-0 |pmid=25376546}}</ref> 

Some people with chronic pain may benefit from [[opioid]] treatment while others can be harmed by it.<ref name="Reuben2015" /><ref>{{cite journal |display-authors=6 |vauthors=Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, Dana T, Bougatsos C, Deyo RA |date=February 2015 |title=The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop |journal=Annals of Internal Medicine |volume=162 |issue=4 |pages=276–286 |doi=10.7326/M14-2559 |pmid=25581257 |s2cid=207538295 |doi-access=}}</ref> 

People with non-cancer pain who have not been helped by non-opioid medicines might be recommended to try opioids if there is no history of [[substance use disorder]] and no current [[mental illness]].<ref name="Bus2017" />

A 2023 review said that future chronic pain diagnosis and treatment would be more personalized and precision based.<ref>{{Cite journal|title=Clinical Diagnosis and Treatment of Chronic Pain|first1=Sadiq|last1=Rahman|first2=Ali|last2=Kidwai|first3=Emiliya|last3=Rakhamimova|first4=Murad|last4=Elias|first5=William|last5=Caldwell|first6=Sergio D.|last6=Bergese|date=December 18, 2023|journal=Diagnostics (Basel, Switzerland)|volume=13|issue=24|pages=3689|doi=10.3390/diagnostics13243689|doi-access=free |pmid=38132273|pmc=10743062}}</ref> 

====Nonopioids====
Initially recommended efforts are [[Analgesic|non-opioid]] based therapies.<ref name=Bus2017>{{cite journal | vauthors = Busse JW, Craigie S, Juurlink DN, Buckley DN, Wang L, Couban RJ, Agoritsas T, Akl EA, Carrasco-Labra A, Cooper L, Cull C, da Costa BR, Frank JW, Grant G, Iorio A, Persaud N, Stern S, Tugwell P, Vandvik PO, Guyatt GH | display-authors = 6 | title = Guideline for opioid therapy and chronic noncancer pain | journal = CMAJ | volume = 189 | issue = 18 | pages = E659–E666 | date = May 2017 | pmid = 28483845 | pmc = 5422149 | doi = 10.1503/cmaj.170363 }}</ref> Non-opioid treatment of chronic pain with pharmaceutical medicines might include [[Acetaminophen|acetaminophen (paracetamol)]]<ref>{{Cite web|title=Acetaminophen Monograph for Professionals|url=https://www.drugs.com/monograph/acetaminophen.html|access-date=2020-06-30|website=Drugs.com|language=en|archive-date=2016-06-05|archive-url=https://web.archive.org/web/20160605063136/http://www.drugs.com/monograph/acetaminophen.html|url-status=live}}</ref> or [[Nonsteroidal anti-inflammatory drug|NSAIDs]].<ref>{{cite journal | vauthors = Conaghan PG | title = A turbulent decade for NSAIDs: update on current concepts of classification, epidemiology, comparative efficacy, and toxicity | journal = Rheumatology International | volume = 32 | issue = 6 | pages = 1491–502 | date = June 2012 | pmid = 22193214 | pmc = 3364420 | doi = 10.1007/s00296-011-2263-6 }}</ref>

Various other nonopioid medicines can be used, depending on whether the pain is a result of tissue damage or is [[neuropathic]] (pain caused by a damaged or dysfunctional nervous system). 

There is limited evidence that [[cancer pain]] or chronic pain from tissue damage as a result of a conditions (e.g. [[rheumatoid arthritis]]) is best treated with opioids. 

For [[neuropathic pain]] other drugs may be more effective than opioids,<ref name="Tauben2015" /><ref name="Welsch2015" /><ref>{{cite journal | vauthors = Vardy J, Agar M | title = Nonopioid drugs in the treatment of cancer pain | journal = Journal of Clinical Oncology | volume = 32 | issue = 16 | pages = 1677–1690 | date = June 2014 | pmid = 24799483 | doi = 10.1200/JCO.2013.52.8356 | hdl-access = free | hdl = 10453/115544 }}</ref><ref>{{cite journal | vauthors = Elomrani F, Berrada N, L'annaz S, Ouziane I, Mrabti H, Errihani H | title = Pain and Cancer: A systematic review | journal = The Gulf Journal of Oncology | volume = 1 | issue = 18 | pages = 32–37 | date = May 2015 | pmid = 26003103 }}</ref> such as [[tricyclic antidepressants]],<ref name="Moore2015">{{cite journal | vauthors = Moore RA, Derry S, Aldington D, Cole P, Wiffen PJ | title = Amitriptyline for neuropathic pain in adults | journal = The Cochrane Database of Systematic Reviews | volume = 7 | issue = 7 | pages = CD008242 | date = July 2015 | pmid = 26146793 | pmc = 6447238 | doi = 10.1002/14651858.CD008242.pub3 }}</ref> [[serotonin-norepinephrine reuptake inhibitors]],<ref name="Gilron2015">{{cite journal | vauthors = Gilron I, Baron R, Jensen T | title = Neuropathic pain: principles of diagnosis and treatment | journal = Mayo Clinic Proceedings | volume = 90 | issue = 4 | pages = 532–545 | date = April 2015 | pmid = 25841257 | doi = 10.1016/j.mayocp.2015.01.018 | doi-access = free }}</ref> and [[anticonvulsants]].<ref name=Gilron2015/> 

Some atypical antipsychotics, such as [[olanzapine]], may also be effective, but the evidence to support this is in very early stages.<ref>{{cite journal | vauthors = Jimenez XF, Sundararajan T, Covington EC | title = A Systematic Review of Atypical Antipsychotics in Chronic Pain Management: Olanzapine Demonstrates Potential in Central Sensitization, Fibromyalgia, and Headache/Migraine | journal = The Clinical Journal of Pain | volume = 34 | issue = 6 | pages = 585–591 | date = June 2018 | pmid = 29077621 | doi = 10.1097/AJP.0000000000000567 | s2cid = 699847 }}</ref> In women with chronic pain, hormonal medications such as oral contraceptive pills ("the pill") might be helpful.<ref>{{cite journal | vauthors = Carey ET, Till SR, As-Sanie S | title = Pharmacological Management of Chronic Pelvic Pain in Women | journal = Drugs | volume = 77 | issue = 3 | pages = 285–301 | date = March 2017 | pmid = 28074359 | doi = 10.1007/s40265-016-0687-8 | s2cid = 35809874 }}</ref> When there is no evidence of a single best fit, doctors may need to look for a treatment that works for the individual person.<ref name=Moore2015/>

[[Nefopam]] may be used when common alternatives are contraindicated or ineffective, or as an add-on therapy. However it is associated with adverse drug reactions and is toxic in overdose.<ref>{{Cite web|url=https://www.sps.nhs.uk/articles/use-of-nefopam-for-chronic-pain/|title=Use of nefopam for chronic pain|date=January 5, 2024|website=SPS - Specialist Pharmacy Service}}</ref>

====Opioids====
In those who have not benefited from other measures and have no history of either [[mental illness]] or [[substance use disorder]] treatment with opioids may be tried.<ref name=Bus2017/> If significant benefit does not occur it is recommended that they be stopped.<ref name=Bus2017/> In those on opioids, stopping or decreasing their use may improve outcomes including pain.<ref>{{cite journal | vauthors = Frank JW, Lovejoy TI, Becker WC, Morasco BJ, Koenig CJ, Hoffecker L, Dischinger HR, Dobscha SK, Krebs EE | display-authors = 6 | title = Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review | journal = Annals of Internal Medicine | volume = 167 | issue = 3 | pages = 181–191 | date = August 2017 | pmid = 28715848 | doi = 10.7326/m17-0598 | doi-access = free }}</ref>

Some people with chronic pain benefit from [[opioid]] treatment and others do not; some are harmed by the treatment.<ref name=Reuben2015/> Possible harms include reduced sex hormone production, [[hypogonadism]], infertility, impaired immune system, falls and fractures in older adults, [[neonatal abstinence syndrome]], heart problems, sleep-disordered breathing, [[physical dependence]], addiction, abuse, and overdose.<ref name=Neurology2014>{{cite journal | vauthors = Franklin GM | title = Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology | journal = Neurology | volume = 83 | issue = 14 | pages = 1277–1284 | date = September 2014 | pmid = 25267983 | doi = 10.1212/wnl.0000000000000839 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Higgins C, Smith BH, Matthews K | title = Incidence of iatrogenic opioid dependence or abuse in patients with pain who were exposed to opioid analgesic therapy: a systematic review and meta-analysis | journal = British Journal of Anaesthesia | volume = 120 | issue = 6 | pages = 1335–1344 | date = June 2018 | pmid = 29793599 | doi = 10.1016/j.bja.2018.03.009 | doi-access = free }}</ref>

It is difficult for doctors to predict who will use opioids just for pain management and who will go on to develop an addiction. It is also challenging for doctors to know which patients ask for opioids because they are living with an opioid addiction. Withholding, interrupting or withdrawing opioid treatment in people who benefit from it can cause harm.<ref name=Reuben2015>{{cite journal | vauthors = Reuben DB, Alvanzo AA, Ashikaga T, Bogat GA, Callahan CM, Ruffing V, Steffens DC | title = National Institutes of Health Pathways to Prevention Workshop: the role of opioids in the treatment of chronic pain | journal = Annals of Internal Medicine | volume = 162 | issue = 4 | pages = 295–300 | date = February 2015 | pmid = 25581341 | doi = 10.7326/M14-2775 | doi-access = free }}</ref>