Chronic pain affects millions of people around the world and can feel like a lonely burden. Whether it stems from persistent back problems, nerve injury, arthritis or an unexplained condition, ongoing pain erodes quality of life and mental health. 

In this guide, we discuss the latest evidence on Pain Management, including pharmacologic therapies, psychological interventions, and interventional procedures. We’ll cover approaches for neuropathic and musculoskeletal pain, so you can make informed decisions about your own pain relief therapy.

Understanding chronic pain and neuropathic pain

Chronic pain lasts for more than three months and can continue long after tissue healing. Unlike acute pain, which signals that the body has been injured, chronic pain often has no protective purpose and can even cause lasting changes in the nervous system. Neuropathic pain management is particularly challenging because it arises from damage or disease of the somatosensory nervous system. 

People describe neuropathic pain as burning, stabbing or tingling. The complexity of its underlying mechanisms means that a single medication rarely suffices. Instead, pain management clinics often take a multimodal approach, combining medicines with physical rehabilitation, psychological care, and, when needed, interventional treatments.

First‑line pharmacologic treatments

For neuropathic pain, first‑line medications target nerve signalling. According to a comprehensive narrative review, first‑line therapies include gabapentinoids (gabapentin, pregabalin), tricyclic antidepressants (amitriptyline, nortriptyline) and serotonin–norepinephrine reuptake inhibitors (SNRIs) such as duloxetine or venlafaxine. These drugs modulate excitability in nerves and improve descending pain inhibitory pathways. Randomized trials show that gabapentin and pregabalin reduce pain in diabetic neuropathy and post‑herpetic neuralgia. However, side effects like sedation, dizziness or weight gain are common. SNRIs often have a more favorable side‑effect profile.

Despite being considered the cornerstone of Neuropathic pain management, first‑line medications are not a cure. A systematic review found that even when these drugs are prescribed correctly, only a minority of patients achieve ≥30–50 % pain relief, with numbers needed to treat (NNT) between four and eight for each drug. This underlines the importance of realistic expectations and the need for complementary strategies.

Dosing and safety

Understanding dosage is essential. Gabapentin is often increased gradually, with doses reaching up to 1,800 mg per day, divided into multiple smaller doses. Extended‑release formulations, such as GRALISE®, may cause fewer side effects and require once‑daily dosing. Pregabalin is usually prescribed between 300 and 600 mg per day, with controlled‑release formulations available. For tricyclic antidepressants, doses range from 25 mg to 150 mg per day, but anticholinergic side effects may limit use. SNRIs, such as duloxetine, are often preferred when tricyclic antidepressants are not well-tolerated. Regular follow‑ups at a pain clinic consultation ensure that doses are optimized and side effects managed.

Second‑line and complementary pharmacologic treatments

Not everyone responds to first‑line agents. Second‑line options include topical therapies and dual‑mechanism drugs. The narrative review explains that 5% lidocaine patches and 8% capsaicin patches or creams block sodium channels or desensitize TRPV1 receptors. These topical treatments provide localized relief with minimal systemic effects and are particularly helpful for post‑herpetic neuralgia or localized neuropathic pain.

Opioid‑like medications such as tramadol and tapentadol have dual action on μ‑opioid receptors and serotonin/norepinephrine pathways. Due to the risk of dependence and side effects, they are typically reserved for patients who have not responded to first‑line therapies. It’s important to emphasize that long‑term opioid therapy is rarely appropriate for chronic neuropathic pain, and guidelines advocate careful monitoring and tapering.

Non‑pharmacological and psychological therapies

While medications play an important role, they are only one aspect of chronic pain treatment. Research shows that non‑pharmacological interventions can reduce pain intensity and improve function. A narrative review highlights that exercise therapy, such as moderate‑intensity strength training, Pilates, and aerobic exercise, reduces chronic pain severity and improves physical function, mood, fatigue, and sleep quality. Massage therapy provides short‑term relief with small‑to‑medium effect sizes on pain intensity.

Psychological interventions are central to Pain Management. Cognitive‑behavioral therapy (CBT) teaches people to modify thoughts and behaviors that amplify pain, while acceptance and commitment therapy (ACT) encourages psychological flexibility. Evidence indicates that CBT has moderate efficacy for reducing pain and improving quality of life, whereas ACT and mindfulness‑based interventions produce small‑to‑medium improvements. These therapies may be delivered individually or as part of group programs. 

Trupeak™ offers CBT and mindfulness sessions as part of our pain relief therapy to address the emotional impact of persistent pain.

Interventional procedures and third‑line options

When pharmacologic and non‑pharmacologic therapies fall short, back pain therapy and neuropathic pain management may involve interventional procedures. In severe cases, third‑line treatments include N‑methyl‑D‑aspartate (NMDA) receptor antagonists (ketamine), cannabinoids and botulinum toxin A. These agents have limited evidence and are typically used under specialist supervision. Intrathecal drug delivery systems and neurosurgical procedures may be considered for cancer‑related or refractory pain.

Interdisciplinary pain rehabilitation programmes (IPRP)

When medications and procedures do not provide sufficient relief, holistic programs step in. A meta‑analysis of rehabilitation interventions for neuropathic pain evaluated 15 studies involving 764 patients and found that interventions such as cognitive‑behavioral therapy, acceptance and commitment therapy, mindfulness and yoga reduce pain intensity and pain‑related disability. These benefits were mainly observed in the short term (< six months), highlighting the need for ongoing support. Interdisciplinary programs also include education, exercise therapy and work‑related interventions, aiming to help patients live an active life despite pain.

Trupeak™’s Pain Management team follows this model. We bring together physiotherapists, psychologists, physicians, occupational therapists and nutritionists to address every aspect of chronic pain. Programs may include graded exercise to rebuild strength, mindfulness sessions for stress management, ergonomics training for workplace adjustments, and nutritional counseling to reduce inflammation. By empowering patients with knowledge and skills, IPRP helps them regain control.

Choosing the right treatment plan

With so many possible treatments available, deciding on the right starting point can be challenging. A comprehensive evaluation at a Pain management clinic is the first step. Trupeak™’s physicians conduct detailed histories and physical exams, considering factors such as pain type (neuropathic vs. nociceptive), medical history, psychological state, and lifestyle. We might begin with first‑line medications, add non‑pharmacological treatments, and evaluate the response. If progress stalls, we may suggest interventional procedures or refer to surgical specialists. Shared decision‑making ensures that you understand benefits, risks, and realistic expectations at every stage.

FAQs about pain management

Summary

Chronic pain is complex and requires an equally nuanced approach. First‑line therapies gabapentinoids, tricyclic antidepressants, and SNRIs, are the foundation of neuropathic pain management, but only a minority achieve substantial relief. Adding second‑line topical treatments or dual‑mechanism drugs can help. Beyond medications, exercise, CBT, ACT, mindfulness and massage reduce pain and improve physical and emotional well‑being. Trupeak™’s Pain Management clinic combines all these elements, guiding patients through personalised treatment pathways and bringing them closer to lasting relief.