Nonopioid Therapies for Pain Management

Acute pain

Nonopioid therapies are at least as effective as opioids for many common types of acute pain.

Clinicians should maximize use of nonpharmacologic and nonopioid therapies as appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. Many acute pain conditions can often be managed most effectively with nonopioid medications. Noninvasive and nonpharmacologic approaches to acute pain also have the potential to improve pain and function without risk for serious harms.

Clinicians can consider using nonopioid therapies to treat common types of acute pain including:

• Low back or neck pain
• Dental pain
• Kidney stone pain
• Pain related to musculoskeletal injuries (such as sprains, strains, tendonitis, and bursitis)
• Pain related to minor surgeries typically associated with minimal tissue injury and mild postoperative pain (e.g., simple dental extraction)
• Headaches, including episodic migraine

For additional information and examples regarding nonopioid and noninvasive nonpharmacologic therapy approaches for treating acute pain, please refer to Recommendation 1 in the 2022 Clinical Practice Guideline

Nonopioid treatment options for acute pain

Nonpharmacologic pain therapies

• Ice
• Heat
• Elevation
• Rest
• Immobilization
• Exercise

Nonopioid medications

• Topical or oral nonsteroidal anti-inflammatory drugs (NSAIDs)
• Acetaminophen
• Triptans, antiemetics, and dihydroergotamine for migraine

Refer to Recommendation 1 in the 2022 Clinical Practice Guideline for additional information and examples of nonopioid therapies to treat acute pain.

Subacute and chronic pain

Nonopioid therapies are preferred for subacute and chronic pain (Recommendation 2).

Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks to the patient.

Nonopioid treatment options for subacute and chronic pain

Nonpharmacologic pain therapies

Many noninvasive, nonpharmacologic approaches can improve pain and function without risk for serious harms. Examples of noninvasive, nonpharmacologic approaches that can be used to manage pain include:

• Exercise (such as aerobic, aquatic, and/or resistance exercise)
• Exercise therapy (a prominent modality in physical therapy)
• Mind-body practices (e.g., yoga, tai chi, qigong)
• Weight loss
• Psychological therapies (e.g., cognitive behavioral therapy)
• Manual therapies
• Mindfulness-based stress reduction
• Low-level laser therapy
• Acupuncture
• Massage
• Spinal manipulation

Exercise, mind-body interventions, and behavioral treatments (including cognitive behavioral therapy and mindfulness practices) can encourage active patient participation in the care plan and help address the effects of pain in the patient's life. Physical activity can provide additional health benefits such as preventing or reducing symptoms of depression.1

Nonopioid medications

Several nonopioid pharmacologic therapies can be used for subacute and chronic pain conditions. Some examples include:

• Topical and oral NSAIDs
• Acetaminophen
• Tricyclic and tetracyclic antidepressants
• Serotonin and norepinephrine reuptake inhibitor (SNRI) antidepressants
• Anticonvulsants (e.g., pregabalin/gabapentin)
• Capsaicin and lidocaine patches

Nonopioid medications are associated with certain risks, particularly in older adults, pregnant patients, and patients with certain comorbidities such as cardiovascular, renal, gastrointestinal, and liver disease.

For more detailed guidance on the use of nonopioid medications to treat acute, subacute, and chronic pain, please refer to the 2022 Clinical Practice Guideline.

Cost concerns

Nonpharmacologic therapies are not always covered or fully covered by insurance. Access and cost can be barriers for patients, particularly people who have low incomes, do not have health insurance or have inadequate insurance, have transportation challenges, or live in rural areas where services might not be available.

Clinicians should become familiar with low-cost options for pain management in their communities so they can refer patients to low-cost services.

For example, for many people, low-cost group aerobics can be as effective as individual physical therapy for reducing low back pain and improving function.

While the cost may vary, physical therapy can be helpful, particularly for patients who have limited access to safe public spaces or public recreation facilities for exercise or have not improved with low-intensity physical exercise.