Alternative Treatments for Chronic Pain

Opioids are not the first-line therapy for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.

Providers should consider alternative treatments, including nonpharmacological therapies and non-opioid medications before prescribing opioids for chronic pain. Evidence suggests  that alternative non-opioid treatments can provide safer, effective relief to patients suffering from chronic pain.

Treatments to Consider First

Focus on functional goals and improvement, actively engaging patients in their pain management.

• Identify and address co-existing mental health conditions (anxiety, depression, PTSD)
• Use interventional therapies (corticosteroid injections) in patients who fail standard non-invasive therapies
• Use disease-specific treatments (e.g. triptans for migraines)
• Use multimodal approaches, including interdisciplinary rehabilitation for patient who fail standard treatments, have severe functional deficits, or psychosocial risk factors
• Refer to Munson Medical Center’s multidisciplinary Pain Management Program for patients with acute, chronic, or disease-related pain. Individualized treatment plans may include:
  • Injections
  • Implantable devices
  • Medications
  • Pain Management for cancer
  • Strategies for personal pain management

First-Line Non-opioid Medications
Use first-line medication options preferentially.

• Acetaminophen
• NSAIDs
• Gabapentin/pregabalin
• Tricyclic antidepressants and serotonin/norepinephrine reuptake inhibitors
• Topical agents (lidocaine, capsaicin, NSAIDs)

Recommended Treatments for Common Conditions

Fibromyalgia
Talk with your patient about the diagnosis, treatment, and their role in treatment.

• Nonpharmacological treatments
  • Acupuncture
  • Biofeedback
  • Cognitive behavioral therapy
  • Interdisciplinary rehabilitation
  • Low-impact aerobic exercise (brisk walking, bicycling, swimming, water aerobics)
  • Neuromuscular therapy (therapeutic massage)
• Non-opioid medications
  • FDA-approved: Duloxetine, milnacipran, pregabalin
  • Others: Gabapentin, TCAs

Low Back Pain
Advise patients to remain active and limit bedrest to address this most common pain problem in the United States.

• Nonpharmacological treatments
  • Acupuncture
  • Cognitive behavioral therapy
  • High Intensity Laser Therapy (HILT)
  • Interdisciplinary rehabilitation
  • Low-impact aerobic exercise (brisk walking, bicycling, swimming, water aerobics)
  • Neuromuscular therapy (therapeutic massage)
  • Strengthening exercise (Pilates, yoga) 
• Non-opioid medications
  • First-line: Acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs)
  • Second-line: Serotonin and norepinephrine reuptake inhibitors (SNRIs/tricyclic antidepressants (TCA)

Migraine

• Preventive treatments
  • Anti-seizure medications
  • Avoid migraine triggers
  • Beta-blockers
  • Calcium channel blockers
• Nonpharmacological treatments
  • Acupuncture
  • Biofeedback
  • Cognitive behavioral therapy
  • Low-impact aerobic exercise (brisk walking, bicycling, swimming, water aerobics)
  • Neuromuscular therapy (therapeutic massage)
  • Relaxation techniques (meditation, mindful breathing)
  • TCAs
• Acute treatments
  • Anti-nausea medication
  • Aspirin, acetaminophen, NSAIDs (may be combined with caffeine)
  • Triptans – migraine specific

Neuropathic Pain

• Nonpharmacological treatments
  • Acupuncture
  • Warm laser therapy
• Non-opioid medications
  • Gabapentin/pregabalin
  • SNRIs
  • TCAs
  • Topical lidocaine

Osteoarthritis

• Nonpharmacological treatments
  • Acupuncture
  • High Intensity Laser Therapy (HILT)
  • Low-impact aerobic exercise (brisk walking, bicycling, swimming, water aerobics)
  • Neuromuscular therapy (therapeutic massage)
  • Patient education
  • Weight loss
• Non-opioid medications
  • First-line: Acetaminophen, oral, and topical NSAIDs
  • Second-line: Capsaicin, intra-articular hyaluronic acid (limited number of intra-articular glucocorticoid injections if acetaminophen and NSAIDs insufficient)

OPTION 2 BELOW

Highlight therapeutic options rather than common conditions. For providers, the option below may not be as insightful or thorough in providing guidance for treating patients as the first option focused on common conditions. 

Physical Therapies

Manual Therapy
Research supports a hands-on approach to treating pain. From carpal tunnel syndrome to low back pain, manual therapy can effectively reduce pain and improve movement. Physical therapists may use manipulation, joint and soft tissue mobilizations, as well as other strategies in their care plans. 

Neuromuscular Therapy (Therapeutic Massage) 
Neuromuscular therapy is a form of soft tissue manipulation that aims to treat underlying causes of chronic pain involving the muscular and nervous systems. This medically-oriented form of massage addresses trigger points (tender muscles points), circulation, nerve compression, postural issues, and biomechanical problems that can be caused by repetitive movement injuries. Many forms of pain may respond to massage therapy and reduce the need for medications, including:

• Fibromyalgia
• Low Back pain
• Migraine 
• Osteoarthritis

Low Impact Aerobic Exercise
Low impact aerobic exercise is one of the best ways to eliminate back pain and keep it from returning. In addition, exercise aids in weight loss and promotes overall health and fitness. Exercise also boosts natural endorphins in the body. Activities such as brisk walking, bicycling, swimming, or water aerobics can be beneficial. Even daily activities such as housecleaning and gardening can deliver results. 

Strengthening Exercises
Stretching, strengthening, and conditioning exercises like Pilates, tai chi, or yoga can ease chronic back pain, and reduce the need for pain medication. Strengthening exercises result in stronger muscles that better support the spine and the body’s weight. When properly supported, patients are less likely to suffer injury and back pain. Increased flexibility also aids in movement.

Mental Health Therapies

Cognitive Behavioral Therapy 
Cognitive behavioral therapy (CBT) is a form of talk therapy that helps people identify and develop skills to change negative thoughts and behaviors. CBT says that individuals -- not outside situations and events -- create their own experiences, pain included. CBT acknowledges that the perception of pain is in the brain, so patients can affect physical pain by addressing the thoughts and behaviors that fuel it. By changing their negative thoughts and behaviors, people can change their awareness of pain and develop better coping skills, even if the actual level of pain stays the same.

Relaxation Techniques
Mediation or mindful breathing can help manage pain and anxiety by teaching patients to react to it differently. Patients who practice these techniques become more aware of, and gain more control over, their emotions and realize that they come and go -- they don’t define them. While meditation and mindful breathing do not take away pain or cure what causes it, they can physically change parts of the brain and be an effective tool for pain management. 

Alternative Therapies

Acupuncture
Acupuncture involves the insertion of very thin needles through the skin at strategic points on the body. Traditional Chinese medicine explains acupuncture as a technique for balancing the flow of energy or life force — known as chi (chee) — believed to flow through pathways (meridians) in the body. By inserting needles into specific points along these meridians, acupuncture practitioners believe that energy flow will re-balance.

Many western practitioners view the acupuncture points as places to stimulate nerves, muscles and connective tissue. Some believe that this stimulation boosts the body's natural painkillers.

Warm Laser Therapy 
Class IV laser therapy can be an effective, safe and economical non-surgical treatment for acute and chronic pain management. Warm laser therapy may be appropriate for conditions such as arthritis pain, joint pain, muscle pain, nerve pain, and injuries.