What the Evidence Says About Chronic Pain Medications

Alison reviews the evidence for chronic pain. Strong opioids were no more effective than paracetamol or NSAIDs for chronic musculoskeletal pain, and a slow, patient-led taper usually leaves pain about the same. She explains opioid induced hyperalgesia and tolerance, and double-blinded emergency trials showing IV paracetamol giving relief similar to IV morphine. A review of seven studies found paracetamol no better than placebo, though she argues a 20% gain can matter in chronic pain. A Cochrane review could not judge NSAID efficacy, while UK data show NSAID gut bleeds cause real deaths. She then walks through a 2015 neuropathic pain meta-analysis: number needed to treat of 3.6 for tricyclics, 6.4 for SNRIs, 7.7 and 7.2 for pregabalin and gabapentin, 4.7 for tramadol and 4.3 for opioids, with the resulting first, second and third line recommendations. She closes on why primary care clinicians can help patients weigh side effects against functional benefit and refer for medication review.