The management of persistent pain.

Persistent pain is a complex mix of physical and psychological symptoms and is ideally managed by a biopsychosocial approach. Often the relative contributions of family and personal relationships, finances, work, past pain experiences and personality outweigh those of the nociceptive or neuropathic processes from which most pain originates. Recent advances in our understanding of the pathophysiology of pain may lead to improved drug treatments; however, non-drug treatments--education, lifestyle modification, exercise and reassurance--should be used routinely to improve patients' quality of life. Patients with persistent pain that is difficult to control or has complex psychosocial influences, or who have a history of medication misuse, should be referred to a multidisciplinary pain centre. Selected patients may be offered invasive options such as nerve blocks or spinal-cord stimulation. The best outcomes are achieved in patients treated in group-based pain-management programs using cognitive-behavioural therapy to improve physical function, change unhelpful thinking and improve patients' understanding of their situation.