Non-Opioid and Non-Pharmacologic Treatment Modalities
It is outside the scope of the DHS Opioid Prescribing Improvement Program to provide specific recommendations about non-pharmacologic and non-opioid treatment modalities. The following resources provide a thorough examination and/or overview of the evidence base for non-opioid and non-pharmacologic treatment approaches.
- Utilize alternatives to opioid analgesia for mild-to-moderate acute pain. Consider additional non-opioid pain management for acute pain when opioids are prescribed.
- Introduce multi-modal therapies to all patients in the post-acute pain period. Discuss evidence-based pain management options; discuss the risks and benefits of the options to guide discussion and support shared-decision making.
- Provide basic pain education during the post-acute and chronic pain period to all patients. Basic pain education resources include patient handouts and online resources.
- Consider pain education—such as therapeutic neuroscience education—for patients whose pain experience is disproportionate to the nature of the injury or pathology, or who are found to be at high risk for chronicity or disability. Therapeutic neuroscience education involves education about the brain, spinal cord and descending pathway nature of pain. Refer patient to an appropriate clinician, such as a pain psychologist or a physical therapist.
- Implement a multidisciplinary approach to treating all patients with chronic pain. Tailor treatment modalities to the patient’s individual needs as determined by the biopsychosocial assessment.
Non-opioid analgesics and adjuvant analgesics are equally or more effective than opioid analgesics for most pain types, with potentially less risk of harm to the patient. Appropriate prescribing of non-opioid and adjuvant analgesics will depend on the patient’s diagnosis, symptoms, pain type, comorbid conditions and overall risk for adverse drug events. Non-opioid medications used to treat pain include non-opioid analgesics, nonsteroidal anti-inflammatory drugs (NSAIDS), selected anticonvulsants and selected antidepressants.
Non-pharmacological therapies include, but are not limited to, physical modalities, behavioral approaches, interventional approaches and patient education. Examples include:
- Exercise therapy
- Cognitive Behavioral Therapy
- Group Support Activities
- Spinal manipulation, acupuncture or yoga
- Physical therapy
- Multimodal integrative therapies
- Mindfulness and stress reduction
- Patient education
Emerging research suggests that patient education about the neurobiology and neurophysiology of pain reduces pain, disability, anxiety and stress associated with the pain experience (Louw, 2011). This type of education—often referred to as therapeutic neuroscience education (TNE)—typically includes an educational session or sessions describing the neurobiology or neurophysiology of pain and pain processing by the nervous system. The aim of this type of pain education is to teach patients to re-conceptualize their pain as the nervous system’s interpretation of the threat of injury, rather than an accurate measure of the degree of injury in their tissues.
Multi-disciplinary pain management
The complexities of pain—and specifically chronic pain--requires a multidisciplinary approach to pain management, tailored to the patient’s individual needs and circumstances. Providers should use the biopsychosocial assessment completed during initial visits to guide decision-making about what treatment modalities may be beneficial to the patient.
The ability to treat chronic pain patients using a multidisciplinary approach may be limited due to the provider’s geographic location or practice setting. Clinicians with limited access to specialists and other health care providers should explore telemedicine options for providing multidisciplinary care.
Multi-modal therapy addresses the various biopsychosocial factors that influence the pain experience. Treatment modalities should include those appropriate for the pain diagnosis, as well as comprehensive psychosocial support. Treatment may include, but is not limited to:
- Psychotherapy strategies (e.g., Cognitive-Behavior Therapy (CBT), Acceptance and Commitment Therapy (AACT), Relaxation Therapy, Mindfulness-Based Stress Reduction and hypnosis)
- Complementary and Integrative Medicine (e.g., acupuncture)
- Active physical therapy (e.g., structured exercise program or physical therapy)
- Passive modalities (e.g., spinal manipulation therapy)
- Interventional treatment (e.g., diagnostic injections or therapeutic injections)
- Interdisciplinary pain rehabilitation programs
- Pharmacologic treatment: Non-opioid medications including acetaminophen, anticonvulsants, antidepressants, glucocorticosteroids, muscle relaxants and antispasmodics and non-steroid anti-inflammatory drugs