Assessing Chronic Pain Treatment Practices and Evaluating Adherence to Chronic Pain Clinical Guidelines in Outpatient Practices in the United States


      Chronic pain is a major health concern in the United States. Several guidelines have been developed for clinicians to promote effective management and provide an analytical framework for evaluation of treatments for chronic pain. This study explores sample population demographics and the utilization of various therapeutic modalities in an adult population with common nonmalignant chronic pain (NMCP) indications in U.S. outpatient settings. A cross-sectional study using the National Ambulatory Medical Care Survey (NAMCS) data from 2000 to 2007 was used to analyze various treatment practices for the management of NMCP and evaluate the results in comparison with guidelines. The study population of 690,205,290 comprised 63% females, with 45.17% of patient visits occurring in primary care settings. Treatment with at least 1 chronic pain medication was reported in 99.7% of patients. Nonsteroidal anti-inflammatory agents were the most common treatment prescribed, with use reported in approximately 95% of the patient visits. No other pain medication drug class or nonmedication therapy was prescribed more than 26.4%. These results point to a potential underutilization of many recommended NMCP treatments including combination therapies and the need for enhanced education of chronic pain guidelines.


      This study, representing over 690 million patient visits, contributes to the relative paucity of data on the use of therapeutic modalities in the management of NMCP. These results may assist clinicians and healthcare policymakers in identifying areas where practices are at odds with guidelines with the goal to improve care.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. American Academy of Pain Medicine: AAPM Facts and Figures on Pain. Available at: Accessed September 23, 2008

        • American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons
        Pharmacological Management of Persistent Pain in Persons.
        J Am Geriatr Soc. 2009; 57: 1331-1346
      2. Assessment and Management of Chronic Pain Work Group: Assessment and Management of Chronic Pain. Institute for Clinical Systems Improvement (ICSI). Available at: Accessed August 23, 2010

        • Ausiello J.C.
        • Stafford R.S.
        Trends in medication use for osteoarthritis treatment.
        J Rheumatol. 2002; 29: 999-1005
        • Balkrishnan R.
        • Cook J.
        • Shaffer M.
        • Saltzberg F.
        • Feldman S.R.
        • Fleischer A.
        Analysis of factors associated with prescription of a potentially inappropriate combination dermatological medication among US outpatient physicians.
        Pharmacoepidemiol Drug Saf. 2004; 13: 133-138
        • Balkrishnan R.
        • Rasu R.S.
        • Rajagopalan R.
        Physician and patient determinants of the treatment of sleep difficulties in outpatient settings in the United States.
        Sleep. 2005; 28: 715-719
        • Baumann T.J.
        • Strickland J.
        Pain Management.
        in: Dipiro J.T. Talbert R.L. Yee G.C. Matzke G.R. Wells B.G. Posey L.M. Pharmacotherapy: A Pathophysiologic Approach. 7th edition. McGraw-Hill Medical, New York, NY2008: 989-1003
        • Berkely K.J.
        • Zalcman S.S.
        • Simon V.R.
        Sex and gender differences in pain and inflammation: A rapidly maturing field.
        Am J Physiol Regul Interfr Comp Physiol. 2006; 291: R241-R244
        • Breuer B.
        • Cruciani R.
        • Portenoy R.K.
        Pain management by primary care physicians, pain physicians, chiropractors and acupuncturists: A national survey.
        South Med J. 2010; 103: 738-747
        • Caudill-Slosberg M.A.
        • Schwartz L.M.
        • Woloshin S.
        Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs 2000.
        Pain. 2004; 109: 514-519
        • Chou R.
        • Fanciullo G.
        • Fine P.
        • Adler J.
        • Ballantyne J.
        • Davies P.
        • Donovan M.I.
        • Fishbain D.A.
        • Foley K.M.
        • Fudin J.
        • Gilson A.M.
        • Kelter A.
        • Mauskop A.
        • O'Connor P.G.
        • Passik S.D.
        • Pasternak G.W.
        • Portenoy R.K.
        • Rich B.A.
        • Roberts R.G.
        • Todd K.H.
        • Miaskowski C.
        Opioid treatment guidelines: Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain.
        J Pain. 2009; 10: 113-130
        • Cintron A.
        • Morrison R.S.
        Pain and ethnicity in the United States: A systematic review.
        J Palliat Med. 2006; 9: 1454-1473
      3. Committee on Advancing Pain Research, Care, and Education; Institute of Medicine: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research. Available at: Accessed May 22, 2012

        • Craft R.M.
        Sex differences in opioid analgesia: From mouse to man.
        Clin J Pain. 2003; 19: 175-186
        • Daumit G.L.
        • Crum R.M.
        • Guallar E.
        • Powe N.R.
        • Primm A.B.
        • Steinwachs D.M.
        • Ford D.E.
        Outpatient prescriptions for atypical antipsychotics for African Americans, Hispanics, and whites in the United States.
        Arch Gen Psychiatry. 2003; 60: 121-128
      4. European Medicines Agency: Opinion of the committee for medicinal products for human use pursuant to article 5(3) of regulation (EC) no 726/2004, for nonselective non steroidal anti-inflammatory drugs (NSAIDs). Available at: Accessed November 23, 2010

        • Federman A.D.
        • Litke A.
        • Morrison R.S.
        Association of age with analgesic use for back and joint disorders in outpatient settings.
        Am J Geriatr Pharmacother. 2006; 4: 306-315
        • Fillingham R.B.
        • King C.D.
        • Riberiro-Dasilva M.C.
        • Rahim-Williams B.
        • Riley J.L.
        Sex, gender and pain: A review of recent clinic and experimental findings.
        J Pain. 2009; 10: 447-485
        • Greenspan J.D.
        • Craft R.M.
        • LeResche L.
        • Arendt-Nielsen L.
        • Berkley K.J.
        • Fillingim R.B.
        • Gold M.S.
        • Holdcroft A.
        • Lautenbacher S.
        • Mayer E.A.
        • Mogil J.S.
        • Murphy A.Z.
        • Traub R.J.
        Studying sex and gender differences in pain and analgesia: A consensus report.
        Pain. 2007; 132: S26-S45
        • Gureje O.
        • Von Korff M.
        • Simon G.E.
        • Gater R.
        Persistent pain and well-being: A World Health Organization study in primary care.
        J Am Med Assoc. 1998; 280: 147-151
        • Hochberg M.C.
        • Altman R.D.
        • April K.T.
        • Benkhalti M.
        • Guyatt G.
        • McGowan J.
        • Towheed T.
        • Welch V.
        • Wells G.
        • Tugwell P.
        American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
        Arthritis Care Res. 2012; 64: 455-474
      5. ICD-9-CM Expert for physicians, Volumes 1 & 2: International Classification of Diseases. 9th Revision. Clinical Modification. Sixth Edition. Ingenix, Eden Prairie, MN2009
        • Janke E.A.
        • Collins A.
        • Kozak A.T.
        Overview of the relationship between pain and obesity: What do we know? Where do we go next?.
        J Rehabil Res Dev. 2007; 44: 245-262
        • Johannes C.B.
        • Le T.K.
        • Zhou X.
        • Johnston J.A.
        • Dworkin R.H.
        The prevalence of chronic pain in United States adults: Results of an internet-based survey.
        J Pain. 2010; 11: 1230-1239
        • Knell M.E.
        Rheumatology: Osteoarthritis and rheumatoid arthritis.
        in: Schumock G. Brundage D. Chapman M. Chessman K. Dunsworth T. Fagan S. Kelly W. Rathburn R. Richie D. Semla T. Vasquez E. Pharmacotherapy Self-Assessment Program. 5th Edition. American College of Clinical Pharmacy, Kansas City, MO2005: 41-88
        • Komaroff A.L.
        Selective and nonselective NSAIDs are associated with excess cardiovascular risk.
        Journal Watch, General Medicine. December 29, 2011;
        • Manson J.E.
        Pain: Sex differences and implications for treatment.
        Metabolism. 2010; 59: S16-S20
      6. Mayday Fund Special Committee on Pain and the Practice of Medicine: A call to revolutionize chronic pain care in America: An opportunity in health care reform. Mayday Fund (2009). Available at: Accessed August 8, 2011

        • Meghani S.H.
        • Cho E.
        Self-reported pain and utilization of pain treatment between minorities and nonminorities in the United States.
        Public Health Nurs. 2009; 26: 307-316
        • Miller G.D.
        • Nicklas B.J.
        • Davis C.
        • Loeser R.F.
        • Lenchik L.
        • Messier S.P.
        Intensive weight loss program improves physical function in older obese adults with knee osteoarthritis.
        Obesity. 2006; 14: 1219-1230
      7. National Ambulatory Medical Care Survey: Available at: Accessed July 9, 2012

        • National Center for Health Statistics
        Health, United States, With Chartbook on Trends in the Health of Americans.
        National Center for Health Statistics, Hyattsville, MD2006
        • NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Obesity in Adults (US)
        Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. The Evidence Report. Report No.: 98–4083.
        National Heart, Lung, and Blood Institute, Bethesda, MDSeptember, 1998
      8. Part III: Pain Terms: A Current List with Definitions and Notes on Usage.
        in: Merskey H. Bogduk N. Classification of Chronic Pain, IASP Task Force on Taxonomy. 2nd Edition. IASP Press, Seattle, WA1994: 209-214
        • Portenoy R.
        • Ugarte C.
        • Fuller I.
        • Haas G.
        Population-based survey of pain in the United States: Differences among white, African American, and Hispanic subjects.
        J Pain. 2004; 5: 317-328
        • Rasu R.S.
        • Balkrishnan R.
        • Nahata M.
        Physician prescribing of sleep disorder medications in United States outpatient settings: Factors associated with prescription of high abuse potential and costly medications.
        Clin Ther. 2005; 27: 1970-1979
        • Rasu R.S.
        • Manley H.J.
        • Crawford T.
        • Balkrishnan R.
        Undertreatment of anemia in patients with chronic kidney disease in the United States: Analysis of national outpatient survey data.
        Clin Ther. 2007; 29: 1524-1534
        • Shavers V.L.
        • Bakos A.
        • Sheppard V.B.
        Race, ethnicity, and pain among the U.S. adult population.
        J Health Care Poor Underserved. 2010; 21: 177-220
        • Stojanovki S.
        • Rasu R.S.
        • Balkrishnan R.
        • Nahata M.
        Trends in medication prescribing for children with pediatric insomnia in US outpatient settings.
        Sleep. 2007; 30: 1013-1017
        • Trescot A.M.
        • Helm S.
        • Hansen H.
        • Benyamin R.
        • Glaser S.E.
        • Adlaka R.
        • Patel S.
        • Manchikanti L.
        Opioid guidelines in the management of chronic non-cancer pain: An update of American Society of the Interventional Pain Physicians' (ASIPP) Guidelines.
        Pain Physician. 2008; 11: S5-S62
        • Verhaak P.F.M.
        • Kerssens J.J.
        • Dekker J.
        • Sorbi M.J.
        • Bensing J.M.
        Prevalence of chronic benign pain disorder among adults: A review of the literature.
        Pain. 1998; 77: 231-239
        • Weiner's Pain Management
        A practical guide for clinicians.
        7th edition. CRC Press, Taylor & Francis Group, Boca Raton, FL2006
        • Wisconsin Medical Society Task Force on Pain Management
        Guidelines for the assessment and management of chronic pain.
        Wis Med J. 2004; 103: 13-42