Alternative Help for Pain /

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Alternative Help for Pain

While evidence supports short-term effectiveness of opioids, there is insufficient evidence that opioids control chronic pain effectively over the long term. Furthermore, long-term opioid use has known and serious risks – up to one-quarter of patients receiving prescription opioids over the long-term in a primary care setting struggles with addiction.

Nonopioid medications are better tolerated with greater improvement in physical function and should be the first stop in treating chronic pain outside of cancer treatment, palliative care, and end-of-life care. Here are some treatment ideas from the CDC.

Nonopioid Medication Options



  • Osteoarthritis, chronic lower back pain, migraine

Harms and risks:

  • Can be hepatotoxic at >3-4 grams/day and at lower dosages in patients with chronic alcohol use or liver disease

Other considerations:

  • May be less effective than treatment with Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Selective Cyclooxygenase-2 (COX-2) Selective Inhibitors and NSAIDs

  • Localized osteoarthritis

Harms and risks:

  • May cause gastrointestinal bleeding or perforation
  • May increase renal risks with longer use or high dosage
  • May increase risk of myocardial infarction or stroke with longer use or high dosage

Other considerations:

  • NSAIDs and COX-2 inhibitors are effective for acute and chronic low back pain without sciatica, but have more adverse effects than acetaminophen (Roelofs et al. 2008)

Select Anticonvulsants

Such as Pregabalin, gabapentin, and carbamazepine

  • Neuropathic pain, including diabetic neuropathy, postherpetic neuralgia, or fibromyalgia

Harms and risks:

  • May cause sedation, dizziness, ataxia, or other side effects

Other considerations:

  • Select anticonvulsants may have abuse potential

Select Antidepressants

i.e. Tricyclics (TCAs) and Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)

Neuropathic pain (diabetic neuropathy, postherpetic neuralgia, or fibromyalgia), migraine

Harms and risks:

  • TCAs are relatively contraindicated in severe cardiac disease, particularly in conduction disturbances
  • TCAs have anticholinergic properties

Other considerations:

  • TCAs and SNRIs provide provide effective analgesia for neuropathic pain conditions including diabetic neuropathy and postherpetic neuralgia in patients with or without depression
  • SNRIs are often better tolerated than TCAs
  • Duloxetine is effective at reducing pain in diabetic peripheral neuropathy pain and fibromyalgia at 60 and 120 mg daily dosages (Lunn et al. 2014)
  • Start TCAs at lower dosages, titrate as needed and as tolerated
  • Some studies have demonstrated a moderate improvement in chronic low back pain with tricyclic or tetracyclic antidepressants (Staiger et al. 2011)
  • Consider dosing TCAs at bedtime due to their sedating effects

Topical Agents

i.e. Tricyclics (TCAs) and Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)
Lidocaine, Capsaicin, Topical NSAIDs

  • Localized neuropathic pain, osteoarthritis, and other localized musculoskeletal pain

Harms and risks:

  • Initial flare or burning sensation
  • Irritation of mucous membranes

Other considerations:

  • Can use topical agents as alternative first-line treatments
  • Can be safer than systemic medications
  • Some guidelines recommend topical NSAIDs for localized osteoarthritis pain over oral NSAIDs in patients over 75 years of age to minimize systemic effects and avoid systemic risks of oral NSAIDs
  • Topical lidocaine can be used for localized neuropathic pain
  • Topical capsaicin can be used for musculoskeletal and neuropathic pain

Interventional Approaches

Such as Epidural or intraarticular glucocorticoid injections, arthrocentesis

  • Inflammatory arthritides such as rheumatoid arthritis, osteoarthritis, rotator cuff disease, some radiculopathies

Harms and risks:

  • Epidural injections can be associated with rare but serious adverse events, including loss of vision, stroke, paralysis, and death
  • Can also cause articular cartilage changes in osteoarthritis, joint infection, and sepsis

Other considerations:

  • Can improve short-term pain and function, but these benefits may not be sustained for long periods
  • Removal of an effusion via arthrocentesis may be indicated prior to steroid injection

Nonpharmacologic Treatment Options

Exercise Therapy

Exercise therapy (e.g., walking, swimming, yoga, free weights, etc.) encourages active patient participation in the care plan and provides the opportunity to address the effects of pain in the patient’s life. Exercise therapy can address posture, weakness, or repetitive motions that contribute to musculoskeletal pain; reduce lower back pain; improve fibromyalgia symptoms; and reduce hip and knee osteoarthritis pain. Exercise therapy can also be used as a preventative treatment for migraine.

Key Findings:

  • Can reduce pain and improve function immediately after exercise
  • Improves global well-being and physical function
  • Treatment effects can be sustained for at least 3-6 months
  • Effectiveness is greater in populations visiting a health care provider compared with the general population

Associated Risks:

  • May depend on patient’s existing conditions

Cognitive Behavioral Therapy (CBT)

CBT addresses psychosocial contributors to pain, including fear, avoidance, distress, and anxiety, and helps improve patient function. CBT trains patients in behavioral techniques to help modify situational factors and cognitive processes exacerbating pain. CBT engages patients to be active, teaches relaxation techniques, supports patient coping strategies, and often includes support groups, professional counseling, or other self-help programs.

Key Findings:

  • Has small to moderate positive effect on pain, disability, mood, and catastrophic thinking immediately after treatment when compared with usual treatments or deferred CBT

Associated Risks:

  • None

Multimodal Approach and Multidisciplinary Therapies

Multimodal and multidisciplinary therapies combine exercise and related therapies with psychologically-based approaches. These strategies can reduce long-term pain and disability compared with single-modality care and compared with physical treatments (e.g., exercise) alone.

These therapies involve coordination of medical, psychological, and social aspects of care and should also be considered for patients not responding to single-modality therapy or those having several functional deficits.

If opioids are used, nonopioid medication and nonpharmacologic treatment should also be prescribed as appropriate. Treatment combinations should be tailored depending on patient needs, cost, and convenience. Multimodal and multidisciplinary therapies, however, are not always available or reimbursed by insurance and can be time-consuming and costly for patients.

Recommended Treatments for Common Chronic Pain Conditions

Low back pain

Self-care and education in all patients:

  • Advise patients to remain active and limit bedrest

Nonpharmacological treatments:

  • Exercise, cognitive behavioral therapy, interdisciplinary rehabilitation


  • First-line: acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs)
  • Second-line: Serotonin and norepinephrine reuptake inhibitors (SNRIs)/tricyclic antidepressants (TCAs)


Preventive treatments:

  • Beta-blockers, TCAs, Antiseizure medications, Calcium channel blockers, non-pharmacological treatments such as cognitive behavioral therapy, relaxation, biofeedback exercise therapy), avoid migraine triggers.

Acute treatments:

  • Aspirin, acetaminophen, NSAIDs (may be combined with caffeine); anti-nausea medication; triptans-migraine-specific

Neuropathic pain


  • TCAs, SNRIs, gabapentin/pregabalin, topical lidocaine


Nonpharmacological treatments:

  • Exercise, weight loss, patient education


  • First line: acetaminophen, oral NSAIDs, topical NSAIDs
  • Second-line: Intra-articular glucocorticoid injections if acetaminophen and NSAIDs insufficient)


Patient education:

  • Address diagnosis, treatment, and the patient’s role in treatment

Nonpharmacological treatments:

  • Low-impact aerobic exercise (e.g. brisk walking, swimming, water aerobics, or bicycling), cognitive behavioral therapy, biofeedback, interdisciplinary rehabilitation


  • FDA-approved: Pregabalin, duloxetine, milnacipran
  • Other options: TCAs, gabapentin