Opioids are often a first line of defense in treating chronic and acute pain. But as government agencies and state legislatures take steps to limit opioid prescribing, health systems are taking a harder look at alternative treatments.
Prescribing alternatives can be a challenge; many doctors face resistance from patients and roadblocks from insurance companies. Still, many pain physicians say these therapies are worth exploring, and potentially more effective than opioids.
“Even if a treatment offers 5 to 10 percent benefit for patients, then that's still benefit for someone in pain," says Anita Gupta, vice chair of the Division of Pain Medicine and Anesthesiology at Drexel University College of Medicine.
Here are 10 non-opioid treatment options for patients who are suffering from pain.
Non-steroidal anti-inflammatory drugs
Known as NSAIDs, these drugs — which include aspirin and ibuprofen, are more than just pain relievers. They also reduce inflammation and lower fevers. Many NSAIDs can be purchased over the counter, which means they're widely available and relatively inexpensive. A recent study published in Lancet found that NSAIDs are effective in relieving pain, but prevent blood from clotting. So using them can put patients at an increased risk for heart attack and stroke, as well as gastrointestinal problems and ulcers.
The generic version of Tylenol is easily obtained over the counter and is often used for patients who don't take NSAIDs because of stomach irritation or worries about heart attacks. Like NSAIDs, acetaminophen is useful in relieving pain, but more than 4000 mg should not be taken in 24 hours or acute liver failure may occur. A recent study published in the Journal of the American Dental Association found that 325 mg of acetaminophen taken with 200 mg of ibuprofen provided better pain relief than oral opioids for patients who had teeth extracted.
Anticonvulsant medications are effective in treating neuropathic pain conditions, which can cause burning and shooting sensations, according to the American Chronic Pain Association. Gabapentin (Neurontin) has been shown to be effective in high dosages, according to the American Academy of Family Physicians, but can cause dizziness, headache, diarrhea and confusion. Although anticonvulsants are not habit-forming, the American Chronic Pain Association advises against abrupt discontinued use. The medication is intended to be taken every day, whether or not the patient is experiencing pain.
Even when depression isn't recognized as a factor in a patient's chronic pain, antidepressants can provide relief. Tricyclic antidepressants, such as Amitriptyline, Imipramine and Clomipramine, are particularly effective in treating neuropathic pain. But a study published in Psychiatry (Edgmont) found that tricyclic antidepressants can cause a host of side effects, including weight gain and cardiovascular problems. In 2010, the FDA approved Cymbalta to treat patients with chronic musculoskeletal pain, and it is still the only antidepressant approved by the FDA for treatment of chronic pain. Side effects include dizziness and fatigue.
In this procedure, which was first used in 1931, a physician uses electric currents to decrease pain signals from a specific nerve. "RFA offers the most precise method currently available" for physicians to "control their patients' pain on a longer term basis," said an expert in a review on Medscape. But the procedure is rarely covered by insurance because it is still considered “experimental." Treatments can cost several thousand dollars.
Steroid injections are commonly given to relieve inflammation and pain associated with certain joints. Although frequently used, many physicians say there's a lack of consensus on their effectiveness. A systematic review of literature on the injections published in Anesthesiology found that the treatments might be helpful in the short-term, but there is no conclusive evidence about their long-term effects.
Chiropractors are focused on neuromuscular disorders, and emphasize manual manipulation of the spine. Studies show mixed results, with some studies showing that chiropractic manipulation decreases pain and improves physical function, and others showing that the risks of manipulating the spine might not outweigh the benefits.
Because of mixed study results, insurance doesn't often cover all the costs associated with chiropractic care. Many carriers will cover the cost of short-term care, which can help patients with acute injuries, but coverage can be a challenge for patients who require extensive treatments. Medicare Part B, for example, only covers basic chiropractic care, such as spinal manipulation, but doesn't cover the initial physical exam or X-rays.
Many doctors are hesitant to prescribe mindfulness treatment to their patients because they didn't hear about it in medical school, says Carl Fulwiler, medical director of the Center for Mindfulness in Medicine, Health Care and Society at the UMass Memorial Medical Center.
“It's not a medication or a surgery, so they're not as sure of the science behind it," he says. “And they see it on the cover of Time magazine, so it seems like a New Age fad."
But mindfulness — the practice of acknowledging the present moment and accepting one's feelings — can be a great benefit to patients with chronic pain. Many patients spend much of their time in pain or worrying about when it will come back, and mindfulness helps them accept their situations and can reduce the intensity of pain, Fulwiler says. A study published in the Journal of the American Medical Association in adults with chronic back pain showed that, over the course of 26 weeks, mindfulness treatments resulted in greater improvement in back pain and functional limitations.
There are plenty of consumer offerings for mindfulness, but many are pricey, and the services are rarely covered by insurance.
The Chinese practice involves an experienced practitioner sticking hair-thin needles into the skin at specific points in the body. The insertion is thought to correct imbalances in the flow of energy in the body, which then helps ease pain. The approach is particularly effective in patients with joint-based and orthopedic pain, says Melissa Rathmell, a trained acupuncturist and the director of Integrative Medicine at the University of Massachusetts Medical School.
A review of 29 studies involving 18,000 patients published in the Archives of Internal Medicine found that acupuncture relieved pain by about 50 percent. But insurance coverage is limited, when it exists at all, and treatments can range from $65 to $125 per session.
Cognitive Behavioral Therapy
Many people with unrelenting chronic pain can feel hopeless. Cognitive behavioral therapy can help them practice “acceptance theory," which can lead to changed behaviors and perceptions, and increase a patient's' confidence and self-efficacy for managing pain.
A review published in American Psychologist found that cognitive behavioral therapy had a small to moderate effect on decreasing pain compared to a patient's usual treatment, and a moderate impact on a patient's mood. The therapy could have a greater impact, the authors wrote, if interventions were part of a coordinated approach and incorporated into primary care settings.
Allison Pohle is a writer based in Boston