Algorithms of Pain Treatment

  • Andrew So
  • Karina Gritsenko


The treatment of chronic pain is a complex process that presents physicians with many unique challenges. The subjective nature of pain and its widespread association with many different disease states have led to the development of a systemic approach to pain treatment. More specifically, physicians have focused on the creation of various pain treatment algorithms to methodize approaches to treatment and set standards of care. This chapter will first present the tools commonly utilized in the initial assessment and evaluation of chronic pain patients, which is typically the first step in any pain treatment algorithm. Next, the World Health Organization’s analgesic ladder will be discussed, as it is one of the most widely practiced algorithms in treating chronic pain patients. Lastly, we will explain the current treatment guidelines for various common pain states.


Pain assessment Visual analog scale World Health Organization analgesic ladder Failed back syndrome Pain treatment algorithm Neuropathic pain treatment Fibromyalgia 


  1. 1.
    Nahin RL. Estimates of pain prevalence and severity in adults. United States, 2012. J Pain. 2015;16(8):769–80.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Livshits G, Malkin I, Freidin MB, Xia Y, Gao F, Wang J, et al. Genome-wide methylation analysis of a large population sample shows neurological pathways involvement in chronic widespread musculoskeletal pain. PAIN. 2017;158(6):1053–62.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Gereau RWIV, Sluka KA, Maixner W, Savage SR, Price TJ, Murinson BB, et al. A pain research agenda for the 21st Century. J Pain. 2014;15(12):1203–14.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Varrassi G, Müller-Schwefe G, Pergolizzi J, Orónska A, Morlion B, Mavrocordatos P, et al. Pharmacological treatment of chronic pain – the need for CHANGE. Curr Med Res Opin. 2010;26(5):1231–45.PubMedCrossRefGoogle Scholar
  5. 5.
    Seymour J, Clark D, Winslow M. Pain and palliative care: the emergence of new specialties. J Pain Symptom Manage. 2005;29(1):2–13.PubMedCrossRefGoogle Scholar
  6. 6.
    Dansie EJ, Turk DC, et al. Assessment of patients with chronic pain. Br J Anaesth. 2013;111(1):19–25.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Fillingim RB, Loeser JD, Baron R, Edwards RR. Assessment of chronic pain: domains, methods, and Mechanisms. J Pain. 2016;17(9 Suppl):T10–20.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Practice Guidelines for Chronic Pain Management An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010;112(4):810–33.Google Scholar
  9. 9.
    Searle RD, Bennett MI. Pain assessment. Anaesth Intensive Care Med. 9(1):13–5.CrossRefGoogle Scholar
  10. 10.
    Herr KA, Garand L. Assessment and measurement of pain in older adults. Clin Geriatr Med. 2001;17(3):457–78, vi.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Green L, McGhie J. Assessment of acute and chronic pain. Anaesth Intensive Care Med. 2001;12(1):9–11.CrossRefGoogle Scholar
  12. 12.
    Chien C-W, Bagraith KS, Khan A, Deen M, Strong J. Comparative responsiveness of verbal and numerical rating scales to measure pain intensity in patients with chronic pain. J Pain. 14(12):1653–62.PubMedCrossRefGoogle Scholar
  13. 13.
    Frampton CL, Hughes-Webb P. The measurement of pain. Clin Oncol. 2011;23(6):381–6.CrossRefGoogle Scholar
  14. 14.
    Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP. Validity of four pain intensity rating scales. PAIN. 2011;152(10):2399–404.PubMedCrossRefGoogle Scholar
  15. 15.
    Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain. 1986;27(1):117–26.PubMedCrossRefGoogle Scholar
  16. 16.
    Scott J, Huskisson EC. Graphic representation of pain. Pain. 1976;2(2):175–84.PubMedCrossRefGoogle Scholar
  17. 17.
    Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain. 1983;16(1):87–101.PubMedCrossRefGoogle Scholar
  18. 18.
    Melzack R. The McGill Pain Questionnaire: Major properties and scoring methods. PAIN. 1975;1(3):277–99.PubMedCrossRefGoogle Scholar
  19. 19.
    Ngamkham S, Vincent C, Finnegan L, Holden JE, Wang ZJ, Wilkie DJ. The McGill pain questionnaire as a multidimensional measure in people with cancer: an integrative review. Pain Manag Nurs. 2012;13(1):27–51.PubMedCrossRefGoogle Scholar
  20. 20.
    Dworkin RH, Turk DC, Trudeau JJ, Benson C, Biondi DM, Katz NP, et al. Validation of the Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2) in acute low back pain. J Pain. 2015;16(4):357–66.PubMedCrossRefGoogle Scholar
  21. 21.
    Dudgeon BJ, Ehde DM, Cardenas DD, Engel JM, Hoffman AJ, Jensen MP. Describing pain with physical disability: narrative interviews and the McGill Pain Questionnaire. Arch Phys Med Rehabil. 2005;86(1):109–15.PubMedCrossRefGoogle Scholar
  22. 22.
    Romano JM, Turner JA. Chronic pain and depression: does the evidence support a relationship? PAIN. 1985;23(3):315.CrossRefGoogle Scholar
  23. 23.
    Turk DC, Okifuji A. Assessment of patients’ reporting of pain: an integrated perspective. Lancet. 1999;353(9166):1784–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Beck AT, Ward CH, Mendelson MM, Mock JJ, Erbaugh JJ. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4(6):561–71.PubMedCrossRefGoogle Scholar
  25. 25.
    Ventafridda V, Tamburini M, Caraceni A, De Conno F, Naldi F. A validation study of the WHO method for cancer pain relief. Cancer. 1987;59(4):850–6.PubMedCrossRefGoogle Scholar
  26. 26.
    Reid C, Davies A. The World Health Organization three-step analgesic ladder comes of age. Palliat Med. 2004;18(3):175–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Ahmedzai SH. Window of opportunity for pain control in the terminally ill. Lancet. 2001;357(9265):1304–5.PubMedCrossRefGoogle Scholar
  28. 28.
    Vargas-Schaffer G. Is the WHO analgesic ladder still valid? Twenty-four years of experience. Willowdale: College of Family Physicians of Canada; 2010. p. 514–7, e202 p.Google Scholar
  29. 29.
    Ballantyne JC, Kalso E, Stannard C. WHO analgesic ladder: a good concept gone astray. BMJ. 2016;352:i20.PubMedCrossRefGoogle Scholar
  30. 30.
    World Health Organization. Cancer pain relif and palliative care. Geneva: WHO; 1990.Google Scholar
  31. 31.
    Mercadante S, Fulfaro F. World Health Organization guidelines for cancer pain: a reappraisal. Ann Oncol. 2005;16(suppl_4):iv132–iv5.PubMedCrossRefGoogle Scholar
  32. 32.
    Twycross R, Lickiss N. Pain control and the world health organization analgesic ladder. JAMA. 1996;275(11):835.PubMedCrossRefGoogle Scholar
  33. 33.
    Gallagher EJ, Esses D, Lee C, Lahn M, Bijur PE. Randomized clinical trial of morphine in acute abdominal pain. Ann Emerg Med. 2006;48(2):150–60, e1–4.PubMedCrossRefGoogle Scholar
  34. 34.
    Alam A, Juurlink DN. The prescription opioid epidemic: an overview for anesthesiologists. Can J Anaesth. 2016;63(1):61–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Harden RN. Chronic pain and opiates: a call for moderation. Arch Phys Med Rehabil. 2008;89(3 Suppl 1):S72–6.PubMedCrossRefGoogle Scholar
  36. 36.
    Wilkerson RG, Kim HK, Windsor TA, Mareiniss DP. The opioid epidemic in the United States. Emerg Med Clin North Am. 2016;34(2):e1–e23.PubMedCrossRefGoogle Scholar
  37. 37.
    Manchikanti L, Helm S 2nd, Fellows B, Janata JW, Pampati V, Grider JS, et al. Opioid epidemic in the United States. Pain Physician. 2012;15(3 Suppl):Es9–38.PubMedGoogle Scholar
  38. 38.
    Vital signs: overdoses of prescription opioid pain relievers-United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487–92.Google Scholar
  39. 39.
    Knight KR, Kushel M, Chang JS, Zamora K, Ceasar R, Hurstak E, et al. Opioid pharmacovigilance: a clinical-social history of the changes in opioid prescribing for patients with co-occurring chronic non-cancer pain and substance use. Soc Sci Med. 2017;186:87–95.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Kennedy-Hendricks A, Busch SH, McGinty EE, Bachhuber MA, Niederdeppe J, Gollust SE, et al. Primary care physicians’ perspectives on the prescription opioid epidemic. Drug Alcohol Depend. 2016;165:61–70.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Trescot AM, Helm S, Hansen H, Benyamin R, Glaser SE, Adlaka R, et al. Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians’ (ASIPP) guidelines. Pain Physician. 2008;11(SPEC. ISS. 2):S5–S62.Google Scholar
  42. 42.
    Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opiods for chronic pain United States, 2016. MMWR Recomm Rep. 2016;65(1):1–49.CrossRefGoogle Scholar
  43. 43.
    Jamison RN, Serraillier J, Michna E. Assessment and treatment of abuse risk in opioid prescribing for chronic pain. Pain Res Treat. 2011;2011:941808.PubMedPubMedCentralGoogle Scholar
  44. 44.
    Haldeman S, Dagenais S. A supermarket approach to the evidence-informed management of chronic low back pain. Spine J. 2008;8(1):1–7.PubMedCrossRefGoogle Scholar
  45. 45.
    Last AR, Hulbert K. Chronic low back pain: evaluation and management. Am Fam Physician. 2009;79:1067–74.PubMedGoogle Scholar
  46. 46.
    Herndon CM, Zoberi KS, Gardner BJ. Common questions about chronic low back pain. Am Fam Physician. 2015;91(10):708–14.PubMedGoogle Scholar
  47. 47.
    Qaseem A, Wilt TJ, McLean RM, Forciea M, for the Clinical Guidelines Committee of the American College of P. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the american college of physicians. Ann Intern Med 2017;166(7):514–530.PubMedCrossRefGoogle Scholar
  48. 48.
    Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the american college of physicians and the american pain society. Ann Intern Med. 2007;147(7):478–91.PubMedCrossRefGoogle Scholar
  49. 49.
    Dworkin RH, O’Connor AB, Audette J, Baron R, Gourlay GK, Haanpää ML, et al. Recommendations for the pharmacological management of neuropathic pain: an overview and literature update. Mayo Clin Proc. 2010;85(3 Suppl):S3–S14.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Padin Galea JM, Fernandez-Acenero MJ, de la Fuente JLM. Characteristics of patients with fibromyalgia. Foot (Edinburgh, Scotland). 2017;32:27–9.Google Scholar
  51. 51.
    Jahan F, Nanji K, Qidwai W, Qasim R. Fibromyalgia syndrome: an overview of pathophysiology, diagnosis and management. Oman Med J. 2012;27(3):192–5.PubMedPubMedCentralCrossRefGoogle Scholar
  52. 52.
    Marques AP, Santo AS, Berssaneti AA, Matsutani LA, Yuan SL. Prevalence of fibromyalgia: literature review update. Rev Bras Reumatol Engl Ed. 2017;57(4):356–63.PubMedCrossRefGoogle Scholar
  53. 53.
    Ablin J, Fitzcharles M-A, Buskila D, Shir Y, Sommer C, Häuser W. Treatment of fibromyalgia syndrome: recommendations of recent evidence-based interdisciplinary guidelines with special emphasis on complementary and alternative therapies. Evid Based Complement Alternat Med. 2013;2013:485272.PubMedPubMedCentralGoogle Scholar
  54. 54.
    Macfarlane GJ, Kronisch C, Dean LE, Atzeni F, Häuser W, Fluß E, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017;76(2):318–28.PubMedCrossRefGoogle Scholar
  55. 55.
    Häuser W, Arnold B, Eich W, Felde E, Flügge C, Henningsen P, et al. Management of fibromyalgia syndrome – an interdisciplinary evidence-based guideline. GMS Ger Med Sci. 2008;6:Doc14.PubMedGoogle Scholar
  56. 56.
    Fitzcharles M-A, Ste-Marie PA, Goldenberg DL, Pereira JX, Abbey S, Choinière M, et al. 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain Res Manag. 2013;18(3):119–26.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Andrew So
    • 1
  • Karina Gritsenko
    • 2
  1. 1.Albert Einstein College of Medicine/Montefiore Medical CenterNew York CityUSA
  2. 2.Albert Einstein College of Medicine/Montefiore Medical Center, Montefiore Multidisciplinary Pain ProgramThe BronxUSA

Personalised recommendations