Division of Rheumatology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, USA.
Am J Med. 2012 May;125(5):S1. doi: 10.1016/j.amjmed.2011.10.003.
As detailed in this online CME activity (www.cmeaccess.com/AJM/ChronicPain04), determining pain mechanism is an important aspect guiding treatment selection for chronic musculoskeletal pain states. Although broad classifications provide a framework, any combination of mechanisms may be present in a chronic pain patient, and there is growing evidence that pain states generally considered nociceptive may also involve elements of augmented central nervous system pain processing. Nonopioid analgesics, including serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, and alpha-2-delta ligand anticonvulsants, are the treatments of choice for fibromyalgia and other central neuropathic pain states. Additionally, studies have now shown that certain SNRIs can be effective in treating "classic" nociceptive pain states, such as osteoarthritis, and also are effective for low back pain. In addition to considering biological mechanisms, chronic pain management also involves recognizing and evaluating the contribution of psychological and sociocultural factors that can influence pain chronicity and patient prognosis. A multimodal/multidisciplinary approach incorporating pharmacologic and nonpharmacologic therapy into a program that includes more than 1 discipline is important to improve outcomes in patients with chronic pain.
如本在线 CME 活动（www.cmeaccess.com/AJM/ChronicPain04）所述，确定疼痛机制是指导慢性肌肉骨骼疼痛状态治疗选择的一个重要方面。尽管广泛的分类为框架提供了指导，但任何组合的机制都可能存在于慢性疼痛患者中，并且越来越多的证据表明，一般认为是伤害感受性的疼痛状态也可能涉及增强的中枢神经系统疼痛处理元素。非阿片类镇痛药，包括 5-羟色胺去甲肾上腺素再摄取抑制剂（SNRIs）、三环类抗抑郁药和α-2-δ配体抗惊厥药，是纤维肌痛和其他中枢神经性疼痛状态的首选治疗方法。此外，研究现在表明，某些 SNRIs 可以有效治疗“典型”伤害感受性疼痛状态，如骨关节炎，也对腰痛有效。除了考虑生物学机制外，慢性疼痛管理还涉及认识和评估可能影响疼痛慢性化和患者预后的心理和社会文化因素的贡献。将药物和非药物治疗纳入包括多个学科的方案中的多模式/多学科方法对于改善慢性疼痛患者的结局非常重要。
