Chronic Pain
Chronic pain is a major public health concern affecting millions of individuals worldwide. It significantly reduces quality of life, limits function, and imposes a considerable burden on healthcare systems. Historically, pain management has been overly reliant on pharmacological interventions, especially opioids, which has contributed to rising concerns over misuse, dependency, and inadequate long-term outcomes. There is now a strong international consensus that non-pharmacological treatments should be prioritized as a safer and often more effective approach to managing chronic pain.
According to the International Association for the Study of Pain (IASP) (2020), describes chronic pain as:
“An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage. Chronic pain persists or recurs for longer than 3 months and is either without clear biological value or impact on function and well-being outweighs any adaptive value.” — International Association for the Study of Pain (IASP)
This definition underscores that chronic pain is more than a symptom—it is a complex condition requiring multidimensional assessment and individualized, often interdisciplinary care. The shift toward non-pharmacologic strategies represents a pivotal evolution in modern pain care, supporting improved outcomes and patient empowerment.
Key characteristics of chronic pain:
- Persistent duration — lasting longer than 3-6 months, often extending beyond normal tissue healing time
- Complex etiology — may lack identifiable ongoing tissue damage or clear relationship to original injury
- Disease state — often becomes a condition in itself rather than serving a protective function
- Functional impact — can significantly impair physical function, emotional well-being, and quality of life
- Neuroplasticity changes — may involve central sensitization, where the nervous system becomes hypersensitive to pain signals
- Multidisciplinary management — requires comprehensive approaches including medical, psychological, and rehabilitation interventions
- Secondary effects — can lead to sleep disturbances, depression, anxiety, and social isolation
- Biopsychosocial model — involves complex interactions between biological, psychological, and social factors
The following evidence-based strategies are consistently recommended across the guidelines below as first-line or foundational treatments for managing chronic pain.
(NOTE – Superscripts refer to following numbered sections)
Structured Exercise Programs¹²³⁴⁵
Regular physical activity—tailored to the individual’s capabilities—improves pain, function, and quality of life. Includes aerobic, resistance, aquatic, tai chi, yoga, and motor control exercises.
Cognitive and Behavioral Therapies¹²³⁴⁵
Interventions such as Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) help patients reframe pain-related thoughts, reduce distress, and improve coping.
Multidisciplinary or Interdisciplinary Rehabilitation¹²³⁴
Team-based care that combines physical, psychological, and educational components is particularly effective for complex or long-standing pain.
Patient Education and Self-Management Support¹²⁴⁵
Education about the nature of chronic pain and training in pacing, goal setting, and flare-up management empowers individuals to take an active role in their recovery.
Mind-Body Therapies¹²³⁴
Techniques like mindfulness-based stress reduction (MBSR), progressive muscle relaxation, and biofeedback reduce pain perception and support emotional regulation.
Manual and Physical Therapies¹²³⁴
Non-invasive approaches such as spinal manipulation, massage therapy, and physical therapy improve mobility and reduce discomfort in many patients.
Acupuncture¹²³⁴⁵
May offer short- to medium-term benefits for certain pain conditions, especially when provided by trained professionals and integrated with other care.
Avoidance of Long-Term Opioid Use as First-Line Therapy²⁴⁵
Pharmacological treatments, particularly opioids, are generally not recommended as initial treatment for chronic primary pain due to limited long-term benefit and high risk.
In response to the global burden of chronic low back pain, the World Health Organization (WHO) published a landmark 2023 guideline focused on non-surgical and non-pharmacological management. This guideline targets low- and middle-income settings but offers globally applicable evidence-based recommendations. The WHO emphasizes a patient-centered approach that prioritizes safety, access, and equity in pain care. It reinforces non-pharmacologic interventions as first-line options, especially in primary care.
The WHO recommends non-surgical, non-drug interventions for adults with chronic primary low back pain, particularly where pharmacologic and invasive options carry higher risks or limited availability. These interventions are chosen for their low harm potential, cultural acceptability, and evidence of benefit in function and quality of life. The WHO underscores the need to prioritize interventions that are scalable and suitable across diverse health systems. The guideline also outlines implementation strategies including training, reimbursement alignment, and the importance of monitoring outcomes.
Recommended Non-Pharmacological Treatments:
- Structured, individualized exercise therapy
- Multidisciplinary rehabilitation
- Cognitive behavioral therapy (CBT)
- Spinal manipulation
- Acupuncture (with consideration of setting and provider training)
- Patient education on pain self-management
- Mind-body approaches such as mindfulness and relaxation techniques
Reference: World Health Organization. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. Geneva: WHO; 2023.
The CDC’s 2022 update to its opioid prescribing guideline places strong emphasis on non-pharmacologic treatments for chronic pain. Recognizing the harms of long-term opioid use and the often limited benefits, the guideline urges clinicians to first pursue safer alternatives. It frames chronic pain as a condition best addressed through a multimodal approach. Non-drug therapies are recommended either as standalone options or in conjunction with non-opioid medications.
This comprehensive 2022 CDC guideline includes 12 recommendations, with several dedicated specifically to chronic pain. It underscores the importance of functional improvement over symptom elimination. The guideline discourages reliance on opioids and suggests that evidence-based non-pharmacologic interventions can often produce equal or greater benefits in terms of pain, function, and quality of life—without the risks. Shared decision-making, cultural sensitivity, and patient access are central principles. The CDC also encourages system-level supports, such as insurance coverage for recommended therapies.
Recommended Non-Pharmacological Treatments:
- Exercise therapy (e.g., walking, aquatic therapy, strength training)
- Cognitive behavioral therapy (CBT)
- Interdisciplinary rehabilitation programs
- Mindfulness-based stress reduction
- Physical therapy and occupational therapy
- Acupuncture and manual therapy
- Behavioral interventions for sleep, mood, and activity pacing
Reference: Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids — United States, 2022. MMWR Recomm Rep. 2022;71(3):1–95.
This widely cited guideline from the American College of Physicians addresses treatment of low back pain across acute, subacute, and chronic phases. For chronic cases, it strongly recommends noninvasive, non-drug therapies as the first-line approach. ACP developed these recommendations through rigorous systematic reviews and consensus from internal medicine experts. It prioritizes interventions that improve pain and function while minimizing harm.
The ACP guideline categorizes recommendations based on the quality of supporting evidence, and for chronic low back pain, drug-free approaches are front and center. These include physical modalities (like exercise and spinal manipulation), mind-body techniques (like yoga and tai chi), and psychological interventions (such as CBT). ACP stresses tailoring the approach to patient preferences, comorbidities, and accessibility. The guideline also recommends avoiding opioids unless other therapies have failed and benefits outweigh risks.
Recommended Non-Pharmacological Treatments:
- Exercise therapy (aerobic, strengthening, or motor control)
- Multidisciplinary rehabilitation
- Acupuncture
- Mindfulness-based stress reduction
- Tai chi and yoga
- Progressive muscle relaxation
- Electromyography biofeedback
- Cognitive behavioral therapy (CBT)
- Spinal manipulation
- Low-level laser therapy and operant therapy
Reference: Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the ACP. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the ACP. Ann Intern Med. 2017;166(7):514-530.
The U.S. Department of Veterans Affairs and Department of Defense updated their clinical guideline in 2022 to reflect the latest science in chronic pain management. Designed for military and veteran populations, it has broader applicability to general healthcare systems. A key tenet is to address pain holistically, prioritizing self-management and evidence-based non-drug therapies. The guideline provides an extensive menu of recommended behavioral and rehabilitative strategies.
The VA/DoD guideline stresses the integration of non-pharmacologic therapy before initiating or continuing opioid use. It highlights whole-person care, encouraging providers to address pain in the context of psychological health, function, and quality of life. CBT, exercise, and team-based care models are particularly emphasized. It also recognizes the role of comorbid conditions such as PTSD or depression. The recommendations are designed for long-term pain conditions, with practical tools for implementation across primary care and specialty clinics.
Recommended Non-Pharmacological Treatments:
- Cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT)
- Exercise and physical therapy (individualized plans)
- Interdisciplinary rehabilitation (e.g., team-based clinics)
- Yoga and tai chi
- Chiropractic care and spinal manipulation
- Acupuncture
- Biofeedback and relaxation techniques
- Pain education and goal-setting strategies
Reference: VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. Version 4.0 – 2022. U.S. Department of Veterans Affairs, Department of Defense.
Link: VA/DoD Clinical Practice Guideline for the use of Opioids in the Management of Chronic Pain
The UK’s National Institute for Health and Care Excellence (NICE) issued Guideline NG193 in 2021 to address chronic pain from both primary (non-specific) and secondary causes. It departs from pharmacologic-centered care by explicitly recommending against starting opioids, NSAIDs, and other medications for chronic primary pain. Instead, NICE promotes psychologically informed and function-focused approaches. The guidance is meant for GPs, physiotherapists, psychologists, and others in community settings.
NG193 is notable for its clear stance against most pharmacologic interventions for chronic primary pain, citing poor benefit-risk profiles. Instead, it promotes person-centered care involving education, shared decision-making, and non-drug strategies. NICE encourages individualized goal-setting and patient involvement in choosing among therapies. The guideline also addresses implementation, calling for better clinician training, improved service access, and reduction in stigma surrounding chronic pain. It offers tools and quality metrics to support adherence across NHS systems.
Recommended Non-Pharmacological Treatments:
- Supervised group exercise programs
- Cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT)
- Acupuncture (within defined limitations)
- Psychological support to address mood and anxiety
- Patient education and goal-setting
- Avoidance of routine pharmacological treatment unless in special circumstances
Reference: National Institute for Health and Care Excellence (NICE). Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE guideline [NG193]; 2021.