Abstract
Management of chronic pain is multidisciplinary, but pharmacotherapy is one of the mainstays of pain management. As applies in all medical therapies, clinicians must strive to achieve the best possible outcome for patients in terms of maximising benefit and minimizing risks, and ensure that this is conducted for each treatment and as an integral element in selecting appropriate therapies. If the balance between risk and benefits is not achieved and understood by the patient.
 Chronic pain patients may already experience a degree of stigmatisation, which can be further exacerbated by evolving socio-political pressures in respect of analgesic availability and accessibility. Hence, we have a Catch-22 situation in which patients become ensnared; they may need supervised access to legitimate analgesic medication(s) but these are not easily accessible because of concerns of the analgesic side-effects and abuse/misuse potential influencing both the individual and wider society. 
 In this paper, we review the evidence in respect of analgesic use in chronic pain. We highlight the importance of: 1) better education and awareness of the problem, 2) evaluate the balance between effect and side effects rather than focusing on pain intensity alone, and include such composite measures in clinical trials, 3) identification of responders to treatment and systematic monitoring for misuse and 4) the use of big data to guide politicians away from inappropriate regulatory restrictions. Such a strategy will improve pain treatment and due to the major costs associated with chronic pain it will also be of benefit for society.
Highlights
Chronic pain has per May 2019 been adopted by the World Health Organization (WHO) to the new international classification of diseases, International Classification of Diseases 11th Revision (ICD-11) [1]
The use of cannabinoids has increased in a number of European countries advocated by legalization of cannabis for recreational and medical use, but Antidepressants and anticonvulsants are drugs with the most results [65]
In this review we focus on management of chronic pain
Summary
Chronic pain has per May 2019 been adopted by the World Health Organization (WHO) to the new international classification of diseases, ICD-11 [1]. Some pharmacological treatment regimens provide relief in pain intensity, that relief may only be significant for a minority of patients and improved management is an unmet need. Even if the recommended medication may improve pain, adverse effects often limit their use due to tissue damage or reduced compliance. This leaves the choice of pharmacological treatment in a conflicting “Catch22”-like dilemma between efficacy, adverse effects, misuse/abuse or addiction potential. Consequence of the above situation is that patients with chronic pain are treated with analgesics that are expensive, but are without documented longterm efficacy, cause serious adverse effects, and have a high risk of addiction and misuse/abuse as depicted in figure 1. The aims of this review are to: 1) briefly discuss the efficacy and side effects of analgesics in chronic pain; 2) review the catch-22 dilemma for pharmacological management of chronic pain and 3) provide new ideas to circumvent the dead end for pain management
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