Chronic Pain: The Complete Guide

Key numbers at a glance

What chronic pain is

Chronic pain is usually defined as pain that lasts or keeps coming back for more than 3 months. It is one of the most common reasons adults in the US see a doctor, and CDC survey data suggest that roughly one in five adults lives with it. For a smaller group, pain limits life or work activities on most days, which is sometimes called high-impact chronic pain.

Chronic pain comes in several broad forms. Some is linked to an ongoing condition such as osteoarthritis, rheumatoid arthritis or endometriosis. Some is neuropathic, caused by damage or disease in the nerves themselves, as in diabetic neuropathy or after shingles. And some is chronic primary pain, such as fibromyalgia, many cases of chronic low back pain, and some headaches, where no single structural cause explains the pain.

Whatever the type, the pain is real. Not finding a clear cause on a scan or blood test does not mean it is imagined, exaggerated or "all in your head". It means that the explanation lies in how the nervous system is processing signals, which is a physical process, rather than in ongoing damage to a joint, muscle or disk.

Why pain can continue after healing

Acute pain is a protective alarm. When you sprain an ankle, nerves in the tissue send signals to the spinal cord and brain, and the brain produces pain to make you protect the injury while it heals. Most tissues heal within weeks to a few months. In chronic pain, the alarm often keeps sounding after the danger has passed, and sometimes becomes more sensitive over time.

This process is called sensitization. Nerves in the spinal cord and brain become more responsive, so ordinary signals such as pressure, movement or temperature are amplified and felt as pain. It explains several things people with chronic pain notice: pain spreading beyond the original area, pain from light touch, and pain that varies with sleep, stress and mood. None of that means the pain is less real. It means the volume control in the nervous system has been turned up. Understanding this changes what treatment aims to do. If pain no longer reliably signals damage, then resting until it goes away often makes things worse, and gradually doing more becomes safe and helpful. Many treatments for chronic pain, including graded exercise, psychological therapies and better sleep, work at least partly by calming that over-sensitive system.

What makes pain more likely to persist

Nobody chooses chronic pain, and many people develop it without any obvious risk factor. Still, some things make it more likely that acute pain will become long-term, or that existing pain will become more disabling. Several of them can be changed, which is why they matter, and why your care team may ask about sleep, mood, work and activity as well as the pain itself.

Physical factors include older age, previous injuries or surgery, arthritis, diabetes, obesity, smoking and low levels of physical activity. Sleep is especially important: short or broken sleep lowers the threshold at which you feel pain the following day, and pain in turn disrupts sleep, setting up a cycle. Psychological and social factors also play a part, including depression, anxiety, high stress, past trauma, fear that movement will cause harm, and isolation or job loss.

Fear and avoidance deserve special mention. If you believe that every twinge means damage, it is natural to stop moving. Over weeks, muscles weaken, joints stiffen, fitness falls and normal activity becomes more painful, which seems to confirm the fear. Recognizing this loop is often the first step out of it, and it is why clinicians may ask about your beliefs and worries as well as your symptoms.

How chronic pain is assessed

Assessment starts with a careful history and examination. Your doctor will want to know where the pain is, when it began, what it feels like, what makes it better or worse, how it affects sleep, mood, work and relationships, and what you have already tried. The quality of the pain is especially useful: burning, shooting or electric pain with numbness or tingling suggests a nerve problem, which responds to different treatments from aching joint or muscle pain.

Tests have a role in ruling out specific causes, but scans are often less helpful than people expect. Many people without any pain have disk bulges, wear-and-tear changes or other findings on MRI, so a scan can show changes that are not the cause and can lead to worry or unnecessary procedures. For most low back pain without warning signs, imaging is not needed early on. When a test is suggested, it is reasonable to ask what it might change about your care. A good assessment also looks for warning signs that point to something other than chronic pain. These include pain with fever, unexplained weight loss, a history of cancer, new weakness or numbness, pain that wakes you consistently at night, or bladder or bowel changes. These need to be checked whether or not you already have a chronic pain diagnosis.

The approach US guidance recommends

Federal guidance, including the HHS Pain Management Best Practices report and the CDC's 2022 opioid prescribing guideline, describes chronic pain care as multimodal: several approaches used together, tailored to the person, with shared decisions between patient and clinician. The CDC guideline specifically says that non-drug therapies and non-opioid medicines are preferred for chronic pain, and that opioids should be considered only if expected benefits outweigh the risks.

In practice, the core of most plans is a combination of physical activity or physical therapy, psychological approaches such as cognitive behavioral therapy, attention to sleep and mood, and medicines where they help. Other options with some evidence for particular conditions include acupuncture, massage, yoga, tai chi and spinal manipulation, and for some people, procedures such as injections or nerve blocks. The goals are also different from acute pain. Complete relief is uncommon in long-standing pain, so care focuses on function and quality of life: walking further, sleeping better, returning to work or a hobby, and having fewer and shorter flares. Many people find that when function improves, pain also eases, even if it does not disappear.

Movement and exercise

Exercise is one of the best-supported treatments for chronic pain, including low back pain, osteoarthritis and fibromyalgia. It strengthens muscles that support joints, improves fitness and sleep, lifts mood and helps calm the sensitized nervous system. The evidence does not strongly favor one type over another, so the best exercise is one you enjoy enough to keep doing: walking, swimming, cycling, strength training, yoga and tai chi are all reasonable options.

Start below what feels possible and build slowly. When you begin, it is common for pain to increase a little during or after activity. In established chronic pain that has been assessed, this "hurt" usually does not mean "harm", and it tends to settle as your body adapts. A physical therapist can design a program that suits your condition and help you progress safely, and many people find supervised group classes easier to stick with. The long-term target for most adults is the same as in the Physical Activity Guidelines for Americans: 150 minutes of moderate activity a week plus muscle-strengthening on 2 days. If you are starting from very little, that may take months to reach, and any increase from your current level is worthwhile.

When to stop and get checked

Stop and get assessed for new weakness, new numbness, a joint that gives way, swelling, or pain that is sharp and clearly different from your usual pattern. Chest pain, severe breathlessness or fainting during exercise need emergency care. These are not part of the expected adjustment to activity, and they need checking by a doctor before you continue with the exercise program.

Pacing and managing flares

Many people with chronic pain fall into a boom-and-bust pattern: on a good day they do everything they have been putting off, pay for it with a flare, rest for several days, and start again. Over time, the busts get longer and the overall level of activity falls. Pacing breaks that cycle by spreading activity evenly so that you can sustain it on good days and bad.

To pace, first find your baseline: the amount of an activity you can do on a bad day without causing a flare. Use time or quantity rather than how you feel, because pain often lags behind activity. For example, if you can garden for 15 minutes without a flare, set 15 minutes, and stop when the time is up, not when it hurts. Break bigger tasks into shorter blocks with breaks built in. Once the baseline feels steady for a week or two, increase by a small amount and hold again.

Flares are a normal part of chronic pain rather than a sign of new damage or that treatment has failed. Writing a flare plan while you are well makes them less frightening. A typical plan says how you will reduce, but not stop, activity; which medicines you will use and for how long; what else helps, such as heat, gentle movement and relaxation; and who to contact if the flare is different from usual. Complete rest for days tends to prolong a flare.

Psychological therapies, sleep and mood

Being referred to a psychologist for pain is easily heard as being told the pain is imaginary. It is not. Psychological therapies are recommended treatments because pain is processed in the brain, and thoughts, emotions, stress and attention all change how strongly it is felt. Cognitive behavioral therapy (CBT) helps you identify unhelpful thoughts and patterns, such as catastrophizing or avoiding activity, and practice more helpful ones. Acceptance and commitment therapy (ACT) focuses on living according to your values alongside pain rather than putting life on hold until it goes. The aim of these therapies is better function and quality of life, which often brings some reduction in pain as well. They can be delivered individually, in groups or through structured digital programs, and many pain rehabilitation programs combine them with exercise. Most of the change happens in the practice between sessions.

Depression and anxiety are common in people with chronic pain and make it harder to bear. Both are treatable, and treating them is part of treating the pain. Sleep deserves the same attention. For long-term insomnia, the American Academy of Sleep Medicine recommends CBT for insomnia (CBT-I) as the first treatment rather than sleeping pills. Its key elements include a fixed wake-up time every day, getting out of bed if you have been awake for about 20 minutes, and getting daylight soon after waking. Alcohol and opioids both reduce sleep quality.

Medicines: what they can and cannot do

Medicines can help some types of chronic pain, but for most people they are one part of the plan rather than the whole answer, and benefit is often partial. The right choice depends on the type of pain, your other conditions and the other medicines you take, so decisions should be made with your doctor or pharmacist. Try one change at a time, at an adequate dose and for long enough to judge, and agree in advance what success would look like.

Over-the-counter pain relievers

Acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen can help some musculoskeletal pain and osteoarthritis. Acetaminophen is in hundreds of combination products, including cold and flu remedies, so check labels to avoid doubling up. FDA guidance is that adults should not take more than 4,000 mg in a day from all sources, and people who drink alcohol regularly or have liver disease should ask their doctor about a lower limit. NSAIDs can cause stomach bleeding, kidney problems and raised blood pressure, and are not suitable for everyone, especially older adults or people with heart, kidney or stomach conditions. Topical NSAID gels are an option for some joint pain.

Medicines for nerve pain and fibromyalgia

Neuropathic pain responds poorly to standard pain relievers. Commonly used options include certain antidepressants, such as duloxetine or amitriptyline, which act on pain pathways at doses that may differ from those used for depression, and the gabapentinoids gabapentin and pregabalin. Topical lidocaine or capsaicin may help localized nerve pain. The FDA has warned that gabapentinoids can cause serious breathing problems, particularly when combined with opioids or other sedatives, in older adults and in people with lung disease. A few medicines are FDA-approved for fibromyalgia, and benefit is modest for many people. Do not stop any of these abruptly without advice.

Opioids

Opioids such as oxycodone, hydrocodone, morphine and tramadol have a place in severe acute pain, cancer pain and end-of-life care. For long-term non-cancer pain, evidence for lasting benefit is limited while risks accumulate: tolerance, physical dependence, constipation, hormonal effects, falls, opioid use disorder and overdose. The CDC 2022 guideline advises clinicians to use the lowest effective dose, notes that risks rise without clear added benefit at or above 50 morphine milligram equivalents (MME) a day, and advises against abrupt stopping or rapid dose reduction for people already on long-term opioids. Tapering, when it is right, should be gradual, planned together and supported.

Anyone taking opioids should keep naloxone at home and make sure family know where it is and how to use it. Naloxone nasal spray reverses opioid overdose and is available over the counter. Avoid combining opioids with alcohol, benzodiazepines, gabapentinoids or sleep medicines unless your doctor has reviewed the combination, since each adds to the risk of slowed breathing, and the combination is more dangerous than either alone.

Specific groups and conditions

The principles of chronic pain care apply widely, but some groups need particular care with medicines and specific conditions have their own priorities. Age changes how the body handles many drugs, pregnancy changes which ones are safe, and children need doses worked out for their weight. People with kidney, liver, heart or lung disease, or who take several medicines, should always check with a doctor or pharmacist before adding a pain reliever, including one bought over the counter.

Older adults

Pain is common in later life, often from osteoarthritis, and it is sometimes under-treated because people assume it is just part of aging. Older adults are more sensitive to side effects, including stomach bleeding and kidney problems from NSAIDs and falls and confusion from opioids, gabapentinoids and some antidepressants. A regular medicine review with a doctor or pharmacist is worthwhile. Gentle strength and balance work, such as tai chi, can reduce pain and the risk of falls at the same time.

Pregnancy

Back and pelvic pain are common in pregnancy, and many pain medicines carry specific risks to the baby. NSAIDs are generally avoided later in pregnancy unless a doctor advises otherwise. Talk to your OB-GYN or midwife before taking or stopping any pain medicine, including over-the-counter products, and ask about physical therapy, which can help pregnancy-related pelvic pain. Gentle activity, supportive belts and changes to how you sit and lift may also ease symptoms.

Children and teens

Children and teens can develop chronic pain too, including headaches, abdominal pain and widespread pain. Similar principles apply: staying in school, staying active, sleep and psychological support. Never give aspirin to children or teens because of the risk of Reye syndrome, and check doses with your child's doctor or pharmacist. Pediatric pain programs can help when pain is affecting school or daily life.

Fibromyalgia and neuropathy

Fibromyalgia, which affects about 4 million US adults, around 2 percent, causes widespread pain with fatigue, unrefreshing sleep and difficulty concentrating. The best-supported treatments are regular, gradually built physical activity, CBT and sleep management. In diabetes, good blood sugar management and daily foot checks matter, because neuropathy can reduce feeling in the feet and allow injuries to go unnoticed. Report any foot wound that is slow to heal.

Procedures, complementary approaches and self-care tools

For some people with specific diagnoses, procedures can help. Examples include steroid injections into an inflamed joint, nerve blocks, radiofrequency treatment of certain spinal nerves, and, for a small number of people with severe nerve pain, implanted nerve stimulators. Results vary widely, relief from injections is often temporary, and every procedure carries some risk. They work best as a way to make exercise and rehabilitation possible, rather than as a stand-alone fix. Surgery helps when there is a clear structural problem that matches the symptoms, such as a severely damaged hip, but it is rarely the answer for widespread or chronic primary pain.

Federal pain guidance also lists complementary approaches with some evidence for certain conditions, particularly back pain, neck pain and osteoarthritis. These include acupuncture, massage, yoga, tai chi, spinal manipulation and mindfulness-based programs. They tend to give modest benefit and are safest when delivered by a qualified practitioner who knows your medical history. Supplements and products marketed as pain cures are a different matter: claims often go well beyond the evidence, and some interact with prescription medicines, so ask your pharmacist before trying them.

Simple self-care tools are worth having in your kit because they give you something to do when pain rises. Heat, from a warm bath or heat pack, eases muscle tension for many people; cold packs can help a swollen or recently strained area. Relaxation breathing, short guided mindfulness exercises and gentle stretching can lower the background tension that amplifies pain. None of these is a cure, but having options you control reduces the sense of helplessness that makes pain harder to live with.

Daily life, costs and talking to your doctor

Access to the full range of pain care varies. Physical therapy and psychological therapy may need a referral, prior authorization or a copay, and some insurance plans limit the number of visits. Ask your plan, or Medicare if you have it, what is covered and what you will pay before you start. Many pain rehabilitation programs, community centers and YMCAs offer exercise classes for people with arthritis or chronic pain at lower cost. Generic versions of many pain medicines are inexpensive; your pharmacist can help compare prices.

Pain scores on a scale of 0 to 10 tell a clinician very little on their own. It is more useful to describe what the pain stops you doing: "I can no longer walk the dog for more than 10 minutes" or "I wake three times a night". Bring a short written summary covering when the pain started, its pattern, what worsens and eases it, the treatments you have tried with dose and result, and your goal, meaning what you most want to be able to do again. When a treatment is offered, ask: What are my options? What are the likely benefits and risks of each? What happens if I wait? How will we know if it is working, and when will we review it? Leaving with a clear next step and a review date is a sign of a good consultation.

Work, relationships and daily life

Chronic pain affects far more than the body part that hurts. It can strain relationships, make work difficult, reduce income and leave people feeling isolated or misunderstood, particularly when the pain is invisible to others. Saying so out loud is often the first step to getting support, and explaining pacing and flares to family helps them understand why you might stop partway through a task on a good day.

Staying connected to work, where that is possible, is generally good for health and recovery. If your job is affected, talk to your employer or HR about changes such as flexible hours, more frequent breaks, a different chair or desk, or a temporary change of duties. Under the Americans with Disabilities Act, people with qualifying conditions may be entitled to reasonable accommodations. Support groups, in person or online through reputable organizations, can reduce isolation and offer practical tips from people who understand.

Myths and a practical four-week plan

Some common beliefs keep people stuck. "Hurt always means harm" is not true in established chronic pain. "I should rest until the pain goes" usually leads to weaker muscles and more pain. "A scan will show what is wrong" overlooks how often findings are unrelated. "Being referred to a psychologist means they think I am making it up" misunderstands how pain works. And "stronger painkillers are the answer" ignores the limited long-term benefit and real risks of opioids. Progress in chronic pain is usually slow and uneven, with good and bad weeks. A month is enough to start building habits that tend to help over time.

• Week 1: Keep a simple diary of activity, sleep, mood and pain; note what you can do on a bad day to set your baseline
• Week 2: Start a short daily walk or other activity at baseline level and stick to time limits; set a fixed wake-up time every day
• Week 3: Write a flare plan; book a review with your doctor to discuss physical therapy, psychological therapies and a medicine review
• Week 4: Increase one activity by a small step if the baseline has felt steady; review your diary and set one function goal for the next month

Every guide in this topic

• What the Guidance Really Says About Chronic Primary Pain
• Pacing Activity: Sorting the Evidence From the Noise
• Opioids for Long-Term Pain: What Published Guidance Supports
• The Evidence on Neuropathic Pain, Without the Hype
• Fibromyalgia: What the Evidence Actually Says
• Psychological Therapies for Pain: What Published Guidance Supports
• What the Guidance Really Says About Sleep and Chronic Pain
• The Evidence on Exercise with Persistent Pain, Without the Hype
• Flare Management: What the Evidence Actually Says
• The Evidence on Talking to Clinicians About Pain, Without the Hype

Frequently asked questions

If my scans are normal, does that mean the pain is not real?

No. Pain is produced by the nervous system, and in chronic pain the system often becomes more sensitive, amplifying ordinary signals. That is a real physical process even when scans and blood tests look normal. Scans are also poor at explaining pain: many people with no pain have disk bulges or joint changes. A normal result usually means no serious structural cause has been found, which is reassuring.

Will exercise make my pain worse?

It may at first, a little, but in established chronic pain that has been assessed, a modest increase in pain with new activity usually reflects sensitivity rather than damage, and it tends to settle as you adapt. Start below what feels possible and build up slowly. Stop and get checked for new weakness, numbness, swelling, a joint giving way, or pain that is clearly different from your usual pattern.

Why was I referred to a psychologist for my pain?

Because psychological therapies are recommended treatments for chronic pain, not because anyone thinks the pain is imagined. Pain is processed in the brain, and stress, sleep, mood, fear and attention all change how strongly it is felt. Therapies such as cognitive behavioral therapy and acceptance and commitment therapy help people do more and cope better, and often reduce how much pain gets in the way.

Are opioids ever appropriate for chronic pain?

Sometimes, but they are not the preferred option. CDC guidance says non-drug therapies and non-opioid medicines should come first, and opioids considered only when expected benefits outweigh risks, at the lowest effective dose, with regular review. Some people already on long-term opioids are doing well on them. If a change is needed, it should be gradual and planned with you, never stopped abruptly.

How much acetaminophen is safe?

FDA guidance is that adults should take no more than 4,000 mg a day from all sources, and many labels advise less. Acetaminophen is found in many combination cold, flu, sleep and prescription products, so check every label to avoid taking it twice. If you drink alcohol regularly, have liver disease or are underweight, ask your doctor what your limit should be. Call Poison Control if you think you took too much.

What is pacing and how is it different from resting?

Pacing means doing a steady, planned amount of activity every day, based on what you can manage on a bad day, and increasing it in small steps. Resting means stopping. Pacing avoids the boom-and-bust cycle of overdoing it on good days and crashing afterward, and it gradually raises how much you can do. Use time limits rather than waiting for pain to tell you to stop.

Why does my pain get worse when I sleep badly?

Poor sleep lowers the threshold at which you feel pain the next day, and pain makes it harder to sleep, so the two feed each other. Treating sleep is part of treating pain. The recommended first treatment for long-term insomnia is CBT for insomnia, which includes a fixed wake time and getting out of bed when you cannot sleep. Loud snoring with unrefreshing sleep is worth mentioning to your doctor.

Should I keep naloxone at home if I take opioids?

Yes. Naloxone reverses an opioid overdose and is available over the counter as a nasal spray at pharmacies. Keep it somewhere easy to find, and make sure family members or housemates know where it is and how to use it, since a person who has overdosed cannot give it to themselves. After giving naloxone, call 911 and stay with the person, because its effect can wear off.

What should I do during a flare?

Follow the flare plan you wrote when you were well. Reduce activity to your baseline rather than stopping completely, use what helps you, such as heat, gentle movement and relaxation, and take medicines as agreed with your doctor. Return to your usual level gradually as it settles. See your doctor if the flare is different from usual, lasts much longer, or comes with fever, weight loss or new weakness.

Can chronic pain ever go away completely?

For some people it does, especially when pain has not been present for very long or when an underlying cause such as a damaged joint can be treated. For many others, pain becomes much less intrusive rather than disappearing: they sleep better, do more and have fewer flares. Because a sensitized nervous system can gradually settle, steady work on activity, sleep and mood often brings improvement over months rather than weeks.

When to speak to a doctor

See your doctor for pain that is new or changing, pain that wakes you consistently at night, pain with fever or unexplained weight loss, pain in someone with a history of cancer, or new weakness, numbness or tingling, even if you already have a chronic pain diagnosis. Go to the emergency room or call 911 for numbness around the genitals or anus, new bladder or bowel problems, or weakness in both legs, and for chest pain or severe breathlessness. Call 911 for slow or shallow breathing, extreme drowsiness or inability to wake someone taking opioids, give naloxone if you have it, and stay with them. Call Poison Control at 1-800-222-1222 if someone has taken too much of a medicine. If you have thoughts of harming yourself, call or text the 988 Suicide & Crisis Lifeline at any hour.

Where this comes from

• CDC — Clinical Practice Guideline for Prescribing Opioids for Pain, United States, 2022
• HHS — Pain Management Best Practices Inter-Agency Task Force Report
• MedlinePlus — Chronic Pain
• CDC — Fibromyalgia
• National Institute of Neurological Disorders and Stroke — Peripheral Neuropathy
• FDA — FDA warns about serious breathing problems with seizure and nerve pain medicines gabapentin and pregabalin
• FDA — FDA Approves First Over-the-Counter Naloxone Nasal Spray
• FDA — Don't Double Up on Acetaminophen
• American Psychological Association — Managing chronic pain: How psychologists can help with pain management
• American Academy of Sleep Medicine — Insomnia

How this page was put together

Every figure, recommendation and warning above is taken from the guidance named in Where this comes from. Nothing on this page is inferred, summarized or generalized beyond what those bodies publish: where they give a number, it is their number, and where they are silent, so are we. Pages are rebuilt whenever the underlying record changes. Sign-off by a named clinician, where it has happened, is shown at the top of the page along with the date.

Medical disclaimer

This article is general information, not medical advice. It cannot account for your own history, medication or circumstances. Always speak to your doctor, pharmacist or another qualified health professional before making changes that affect your treatment, and never delay seeking medical advice because of something you have read here. In an emergency, call 911.