Table 3.

International guidelines for chronic pain. SIGN: Scottish Intercollegiate Guidelines Network; CDW: Colorado Division of Workers; AGS: American Geriatric Society; COX: cyclooxygenase; DHHS: Department of Health and Human Services; NeuPSIG: Neuropathic Pain Special Interest Group; NICE: National Institute for Health and Care Excellence; NMDA: N-methyl-D-aspartate; NSAIDs: non-steroidal anti-inflammatory drugs; OTC: over the counter; SNRI: noradrenaline–serotonin reuptake inhibitor; TCA: tricyclic antidepressant.

	STEP I	STEP II	STEP III	STEP IV	STEP V	STEP VI
Nociceptive pain
SIGN [12]	Paracetamol or NSAIDs	Weak opioids or topical NSAIDs	Strong opioids
CDW [49]	NSAIDs or COX-2 inhibitors
AGS [91]	Paracetamol (up to 4 g/day)	NSAIDs	Opioids
DHHS [92]	Ia: paracetamol Ib: ibuprofen or naproxen Ic: paracetamol plus ibuprofen or naproxen	IIa: codeine IIb: tramadol	IIIa: low-dose morphine or buprenorphine patch (if morphine is ineffective) IIIb: high-dose morphine or 5–30 mg of oxycodone twice a day or fentanyl/buprenorphine patch if morphine is ineffective IIIc: 50 mg of tapentadol twice daily
ESCEO [93]	Chondroitin sulfate or glucosamine sulfate	Paracetamol or topical NSAIDs	NSAIDs	Intra-articular injection of hyaluronic acid or corticosteroids	Duloxetine	Surgery
Neuropathic pain
SIGN [12]	Amitriptyline or gabapentin	Pregabalin	SNRIs	5% lidocaine	Opioids	9% capsaicin
CDW [49]	Tricyclic antidepressants	Gabapentin/pregabalin or SNRIs (duloxetine)	Other anticonvulsants	Low-dose opioids
AGS [91]	Duloxetine or pregabalin
DHHS [92]	Amitriptyline/imipramine	Gabapentin (1st line) or pregabalin (2nd line) or 0.075% capsaicin cream	Duloxetine or lidocaine plasters (5%-700 mg/plaster) or capsaicin patch (8%-179 mg/plaster)
Practice [94]	Duloxetine or TCA	Lidocaine or ketamine
NICE [2].	Antidepressants	Gabapentin or pregabalin
NeuPSIG [14]	TCA, SNRI, or gabapentin/pregabalin	Tramadol, lidocaine, and capsaicin patches	Opioids or botulin toxin-A