Transdermal fentanyl (Duragesic and generic) has limited use for treatment of chronic pain. Transdermal fentanyl is a short-acting opioid packaged in a long-acting delivery system, making patients on it especially prone to development of opioid tolerance.

A careful history can indicate the types of pain involved and guide treatment plans. For example, if NSAIDs provide significant relief, an inflammatory component to pain is likely. Note whether other modalities and medications have helped or not, and incorporate that information into the treatment plan.

Discuss options for taking prescription sleeping medicine, including how often and when to take it and in what form, such as pills, oral spray or dissolving tablets

Herbal supplements. Patients frequently request information about herbal supplements. The evidence for the use of some supplements is growing. Many are safe and may be considered when patients are interested. See Table 6.

Garlic is a natural anti-inflammatory that boosts liver enzyme activity, says Cherkaoui. A 2020 study found an intake of garlic powder at 800 milligrams a day for 15 weeks to improve fatty liver disease, liver enzymes, lipid profiles, and fasting blood sugar in patients with non-alcoholic fatty liver disease. Remember: Always talk to your doctor before starting any new supplement.

Sublingual buprenorphine (Suboxone, Subutex and generic) may be prescribed off-label for pain with a regular DEA number. Sublingual buprenorphine has an evolving role, particularly in patients already treated with high dose opioid therapy who continue to complain of uncontrolled pain, and who may or may not have opioid use disorder.

Marijuana. Evidence regarding benefits and harms is currently insufficient to recommend using “medical” marijuana for chronic pain. Some data support cannabidiol (CBD) alone as being relatively safe.

All opioids are essentially similar regarding effects and adverse effects. True allergy to any of them is very rare. Morphine and codeine may be slightly less well tolerated, but can be used unless adverse effects become intolerable or a medical contraindication is present.

Some evidence shows that patients with complex persistent dependence may tolerate transition to buprenorphine better than a tapering down of the opioid dose. When complex persistent dependence is suspected, a more clinically useful approach may be to transition to buprenorphine and then taper down the dose.

Review medication list prior to visit. If medication was trialed previously, why was it stopped? Was there an intolerance? At what dose was each drug tried before labeling as “ineffective”? How long was each drug taken?

To optimize pain management, a thorough history and assessment of pain is required prior to initiating treatment.

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Definition: pain that is perceived at a location other than that of the causative stimulus; projection of pain usually onto a specific dermatome or myotome of the corresponding segment of the spinal cord

The goal of physical therapy is to improve function. Therapeutic exercise, other modalities, manual techniques, and patient education are part of a comprehensive treatment program to accomplish this goal.