Table 2.

Guideline recommendations for drug management of chronic pain

Analgesic class	Recommendation*	Safety concerns	Quality of evidence†
Paracetamol (acetaminophen)	Use for mild to moderate pain	Liver toxicity a concern at higher doses, particularly from unintentional overdose	High
Oral NSAIDs	Use for shortest time possible; may be appropriate when other treatments have failed	Selective and non-selective NSAIDs associated with adverse gastrointestinal, renal, and cardiovascular side effects	High
Topical NSAIDs	Use as alternative to oral NSAIDs, particularly when pain is localized	Safety of topical NSAIDs in patients receiving anticoagulation or with renal impairment remains unknown	Moderate
Tramadol	Consider for use in patients who do not respond to paracetamol/NSAIDs	Increased risk of seizures or serotonin syndrome when used with antidepressants; side effect profile similar to that of opioids	Not reported
Opioids	Use for moderate to severe pain or with substantial impairments in functioning or quality of life and when other treatments have been unsuccessful	Side effects limit use (constipation, sedation, nausea)	Low
Tricyclic antidepressants	Avoid tertiary tricyclics (for example, amitriptyline) because of concerns over adverse side effects; consider trial of secondary amine (nortriptyline) for neuropathic pain	Side effects limit use, electrocardiographic monitoring required owing to risk of QTc prolongation; serum level monitoring also recommended	Moderate
Anticonvulsants (for example, pregabalin, gabapentin)	Use for neuropathic pain	Side effects limit use (for example, sedation, peripheral edema); dose adjustment necessary in those with renal impairment	Moderate

NSAIDs=non-steroidal anti-inflammatory drugs.

*Recommendations present in both UK and US guidelines.^{2 3}

†Quality of evidence ratings are from the 2009 American Geriatrics Society guideline.