Chronic pain management: Match the treatment to the cause

This article by Dr. Kayvan Haddadan was originally published on KevinMD.com on July 3, 2026

 

Chronic pain affects millions and demands a nuanced, individualized strategy. Providers draw from training and comfort zones, but the scientific literature supports a multimodal framework that integrates pharmacological, rehabilitative, psychological, and interventional options. No single modality universally outperforms others. Outcomes improve when treatments target the underlying pain generator, whether nociceptive, neuropathic, inflammatory, or vertebrogenic, while considering patient-specific factors like comorbidities and functional goals.

Pharmacological management

Opioids provide potent analgesia for certain chronic pain states, with evidence of short-term reductions in pain intensity and improvements in function. However, long-term data show variable benefits, potential for tolerance, and risks including opioid use disorder (estimated 3 to 12 percent in treated chronic pain populations, varying by study). The 2022 CDC guidelines prioritize non-opioid therapies for subacute and chronic pain, recommending opioids only when expected benefits outweigh risks, with careful monitoring. The true art of pain medicine lies in skillfully orchestrating this “cocktail” of interventions to match each patient’s unique needs, goals, and circumstances. When successful, this strategy restores function, reduces reliance on emergency departments, enhances quality of life, and enables patients to remain productive members of society. It transforms chronic pain from a disabling condition into a manageable one. It is important to reiterate that the guidelines were routinely misapplied as rigid mandates, causing serious harm. Sharp reductions in legitimate prescribing failed to reduce overdoses and may have driven some patients to deadlier street drugs. Forced tapering or abrupt discontinuation dramatically elevated risks of overdose, suicide, untreated pain, and loss of function.

Many overdoses now stem from illicit synthetics like fentanyl rather than prescribed opioids alone. Complementary non-opioid agents like NSAIDs, acetaminophen, muscle relaxants, antidepressant medication SNRIs/TCAs (which modulate descending inhibitory pathways), and gabapentinoids offer mechanistic diversity and are often first-line or adjunctive.

Interventional and procedural options

Image-guided procedures allow precise targeting of pain sources. Classic approaches include corticosteroid injections (intra-articular, epidural, trigger point, or bursal), medial branch blocks, and radiofrequency ablation for facet-mediated pain. These reduce inflammation, interrupt nociceptive signaling, or provide diagnostic confirmation. Headaches and migraines have their own toolkit with preventives, acute treatments, and sometimes injections like occipital nerve blocks or Botox, which was covered in the past and not covered exhaustively here but important for that subset. There was a good review of how to address knee pain previously that is good to review.

Advanced minimally invasive techniques have expanded options, particularly for lumbar spinal stenosis, vertebrogenic pain, vertebral fractures, and sacroiliac dysfunction:

• Minimally invasive lumbar decompression (MILD): For lumbar spinal stenosis with neurogenic claudication, this percutaneous procedure removes ligamentum flavum hypertrophy and bone to decompress neural elements without open laminectomy. Randomized and real-world data show durable improvements in pain, walking distance, and function, with low complication rates (around 1.9 percent versus higher for open surgery) and high rates of avoiding more invasive decompression (for example, about 88 percent at 5 years in select cohorts).
• Intracept procedure (basivertebral nerve ablation): Targets vertebrogenic low back pain associated with Modic type 1 or 2 changes. Radiofrequency energy ablates the basivertebral nerve within the vertebral body, disrupting a key pain pathway. Level 1 RCTs demonstrate clinically meaningful and sustained reductions in pain and disability (for example, at least 50 percent pain relief in about 65 percent at 6 to 12 months, with benefits persisting 5-plus years). It is a single-treatment, implant-free option with a strong safety profile (less than 0.3 percent serious device or procedure-related events).
• Kyphoplasty: For painful vertebral compression fractures (often osteoporotic or pathologic), this involves balloon-assisted vertebral height restoration followed by cement augmentation. It provides rapid pain relief (often within days), improves biomechanics, and reduces kyphotic deformity risk. Success rates are high, with pain scores frequently dropping significantly (for example, from about 9/10 to about 3/10), and better outcomes than conservative management in appropriately selected patients.
• Sacroiliac (SI) joint interventions: SI joint pain contributes to 15 to 25 percent of chronic axial low back pain. Diagnostic or therapeutic injections (local anesthetic with or without corticosteroid) help confirm the source. For refractory cases, minimally invasive SI joint fusion stabilizes the joint using implants, yielding greater pain reduction, functional gains, and lower opioid use compared to conservative care (including injections and PT) in RCTs, with sustained benefits at 24 months.
• ZIP procedure (interspinous fixation): A minimally invasive implant placed between spinous processes to stabilize the segment without pedicle screws or rods. It addresses instability-related pain (for example, in degenerative disc disease or post-laminectomy syndrome) and can be performed outpatient, offering an intermediate option between conservative care and traditional fusion.

These procedures leverage imaging guidance for precision, minimizing tissue disruption, recovery time, and risks relative to open surgery.

Rehabilitative and psychological modalities

Exercise therapy, physical therapy, and targeted strengthening and stretching address biomechanical contributors and promote endogenous analgesia via endorphins and improved neuromuscular control. Modalities like cold and heat therapies, therapeutic ultrasound, or electrical stimulation provide adjunctive relief through different mechanisms.

Cognitive behavioral therapy (CBT) and related approaches target central pain processing, catastrophizing, and fear-avoidance. Meta-analyses confirm moderate improvements in pain, disability, and mood that persist post-treatment.

Pain neurophysiology primer

Pain signals originate at peripheral nociceptors, ascend via spinal pathways (with modulation in the dorsal horn), and are processed supraspinally. Descending inhibitory systems (involving serotonin, norepinephrine, and endogenous opioids) can be harnessed by medications, stimulation techniques, or behavioral interventions. Advanced procedures like Intracept or spinal cord stimulation directly interface with these pathways.

Toward personalized, multimodal care

Evidence consistently favors individualized, multidisciplinary plans over siloed approaches. Regulatory scrutiny on opioids has accelerated adoption of alternatives, but the core principle remains: Match the intervention to the pathophysiology, weigh benefits and risks with high-quality data, and monitor outcomes rigorously.

Ongoing research refines patient selection like imaging correlates (for example, Modic changes for Intracept), diagnostic blocks, and functional assessments, to optimize success. If you’re navigating chronic pain, consult a specialist experienced in these options. The field continues evolving, with the shared goal of restoring function and quality of life based on the best available science.

 

Originally published on KevinMD.com on July 3, 2026.