Pain Management: Opioid Alternatives
One of the most common reasons that U.S. adults seek medical care is to help alleviate chronic pain. Around 20% of Americans—one out of every five people—are affected by chronic pain conditions.1 And pain management strategies sometimes include the prescription of opioid medications.
Pain Management: Opioid Alternatives
One of the most common reasons that U.S. adults seek medical care is to help alleviate chronic pain. Around 20% of Americans—one out of every five people—are affected by chronic pain conditions.1 And pain management strategies sometimes include the prescription of opioid medications.
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When properly prescribed and used for a short period, opioid medications (aka narcotics) can be useful in treating acute pain associated with an injury or surgery. But when the pain becomes chronic, opioids are generally not the best choice—and carry a high risk of misuse and/or addiction.
The good news is that there are effective alternatives to opioids for pain management. There are other pain relief options that include evidence-supported therapies that can offer relief.
For people who are struggling with chronic pain and may be misusing opioids, this page provides information about the use of opioids for pain management, the potential dangers of such medicines, and effective non-pharmaceutical treatment alternatives for chronic pain.
And for those who are struggling with opioid use disorder—and their concerned loved ones—the signs and symptoms of opioid addiction are also covered, along with treatment options.
Understanding Chronic Pain
Chronic pain is usually defined as pain that lasts for more than three months, despite medication or treatment. This kind of pain might be the result of an injury, an underlying medical disease/condition, surgery, or other medical procedure, or localized or systemic inflammation. Its cause may also be unknown.2
Migraines, back pain, neck pain, diabetes, osteoarthritis, fibromyalgia, and irritable bowel syndrome are just some of the many examples of chronic pain conditions.
Chronic pain can negatively affect almost every aspect of a person’s life. It can reduce mobility, impair physical functioning, trigger emotional distress, and reduce a person’s overall quality of life. Chronic pain often co-occurs with psychological conditions, including mental health and substance use disorders. People experiencing chronic pain are also at an increased risk for suicidal ideation and behaviors.
For all these reasons, the prevention, assessment, and treatment of pain is an ongoing challenge and priority for healthcare professionals. It’s vitally important to acknowledge and provide effective care to individuals who are experiencing chronic pain.
Pain management strategies can be pharmaceutical (involving drugs) or non-pharmaceutical (drug-free). Opioid medicines are one possible pharmaceutical approach to pain management. But how effective are opioids in relieving chronic pain?
When are Opioids Prescribed for Chronic Pain?
While opioid medications can be useful for treating acute pain, they often fail to provide lasting and meaningful relief for pain that has become chronic. And—because of their potential for misuse and addiction—opioids may create more problems than they solve.
Opioid medications are often prescribed and can be effective in reducing acute pain associated with surgery or a serious injury. But their effectiveness in treating chronic pain is much less clear. At best, opioids may “take the edge off” chronic pain for a short time. But daily use of opioid drugs can make the pain worse—by altering the signaling in the central nervous system in a way that makes the body more sensitive to painful stimuli.
No matter how much opioid medication a person takes, the root cause of their chronic pain will not be resolved. Higher doses typically create more side effects. But any dose of an opioid medicine—even a very small one—can be risky; and will do nothing to alleviate the underlying cause of the chronic pain.
2022 CDC Opioid Prescribing Guidelines
The three basic options for treating chronic pain, according to the Centers for Disease Control and Prevention (CDC), are:3
- Noninvasive non-pharmacologic treatments
- Nonopioid pharmacologic treatments
- Opioid treatments
Noninvasive drug-free treatments, when they are available and appropriate, are the #1 preferred option. The second choice, according to CDC guidelines, should be non-opioid medications. In most cases, opioid medicines should only be considered as a third and final option for treating chronic pain.
Opioid Prescription for Acute Pain
Treatment of acute and chronic pain comes with somewhat different guidelines. The current (2022) CDC guidelines for prescribing opioids for Acute Pain begin with these basic principles:
- When opioids are needed for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. In other words, mental health professionals should prescribe the lowest effective dosage for the shortest possible time.
- When beginning opioid therapy, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids.
Opioid Prescription for Chronic Pain
Current (2022) CDC guidelines for prescribing opioids for Chronic Pain begin with this basic principle:
- Opioid medications are generally approved for pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care. In all other cases, extreme caution should be exercised.
Additional specific CDC recommendations for opioid use for chronic pain conditions include:
- Non-opioid therapies are preferred. Opioids should not be considered first-line or routine therapy for chronic pain. Other options for pain management should be explored.
- Pain management care should be individualized, and the benefits and risks of all treatment options should be considered. A patient's history of misuse or addiction to opioids (or other controlled substances) needs to be taken into account when evaluating the benefits and risks of opioid medicines.
- If the benefits of opioid therapy outweigh the risks, doctors should work closely with patients to also include nonopioid therapies as part of their pain management strategy.
Other conclusions reached by the CDC concerning chronic pain management include the following:
- There are several nonpharmacologic treatments as well as nonopioid medications that are just as (or more) effective in relieving chronic pain and improving function than opioid medications.
- Noninvasive therapeutic interventions such as exercise, psychological therapies, complementary and integrative medicine therapies, and mind-body practices can improve chronic pain conditions; and are free from the potentially serious side effects of opioid medications.
- For outpatient pain management, non-opioid therapies are preferred for chronic pain. Healthcare professionals should only consider prescribing opioid therapy if the expected benefits for pain and function are anticipated to outweigh the risks to the patient.
- Patients with co-occurring pain and substance use disorders (including opioid use disorder) require ongoing pain management that maximizes benefits relative to risks. Clinicians should use nonpharmacologic and nonopioid pharmacologic pain treatments whenever possible.
The bottom line is that while opioids may be effective for the management of certain kinds of acute pain, they come with considerable risks. One review of scientific studies found no convincing evidence to demonstrate the long-term benefits of prescription opioid treatment for chronic pain. And long-term prescription opioid use was found to be associated with an increased risk of opioid misuse, addiction, overdose, and other risks.4
For these reasons, opioids are no longer recommended for the treatment of most people with chronic pain.
Signs of Opioid Abuse
Because opioid medications can temporarily relieve painful sensations, people suffering from chronic pain may feel motivated to use these drugs—even against the advice of their healthcare professional. Over time, such individuals may develop an opioid addiction. This is the link between chronic pain and opioid abuse.
What are the signs and symptoms of opioid addiction? 5 Opioid use disorder (OUD)—the official term for opioid addiction—is diagnosed according to the criteria described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). When a person has experienced at least two of eleven symptoms listed in the DSM-5 within the past year, they can be diagnosed with opioid use disorder.
Simply put, the primary symptoms of opioid use disorder include:6
- Frequently using more opioids than intended.
- Having a preoccupation with and craving for opioids.
- Developing a tolerance for opioid medicines—so needing to take higher doses to achieve the same result.
- Continued use of opioids despite significant opioid-related problems—for instance, health problems; failure to fulfill work, family, or social responsibilities; or increasingly unstable relationships.
- Developing a physiological dependence upon the opioid medication; and experiencing withdrawal symptoms.
- Repeated unsuccessful efforts to cut down or control the use of opioids.
Long-term use of opioids can also lead to a condition known as opiate-induced hyperalgesia—a paradoxically increased sensitivity to painful stimuli. This heightened pain sensitization is caused by an increase in the pain signals transmitted to the brain in people with long-term exposure to opioids.
Alternatives for Chronic Pain Management
The good news is that there is a wide range of effective alternatives to opioid pain medications. A variety of opioid alternatives are available to provide relief from chronic pain and support overall health and wellness. People should consult with a medical professional to find an alternative treatment plan that fits their needs.
Pain management options to help manage or resolve chronic pain include the following:
Meditation
There are many different meditation techniques—tools for knowing, transforming, and liberating the mind. Regular meditation practice helps cultivate a healthy, strong, and flexible mind. It can also nourish deep relaxation, inner peace, and joy. And it can support a connection to the aware presence that is the background of all of life’s experiences.
Research has also shown that meditation activates neural pathways that make the brain less sensitive to pain and increases its pain-reducing opioids. Meditation can also release feel-good chemicals such as serotonin, GABA, dopamine, and endorphins that decrease anxiety and regulate mood. This helps unwind the emotional tension that often exacerbates the experience of chronic pain. 7
Simple meditation techniques that can help reduce chronic pain include:
- Paying attention to the movement of the breath and how it feels in the body.
- Noticing physical sensations—slowly scanning from head to toe—without judgment or mental commentary.
- Guided visualization on a positive nurturing image.
- Intentionally focusing on a place in the body that feels comfortable.
Mindfulness-Based Stress Reduction
Mindfulness-based stress reduction (MBSR) is a type of meditation that utilizes body awareness, guided meditation, and breathing exercises to help unwind unnecessary physical and emotional tensions. The many benefits of mindfulness meditation include not only stress reduction but also the alleviation of anxiety and depression and the resolution of chronic pain. 8
Researchers have measured the effects of mindfulness on pain perception and brain activity. What they discovered is that mindfulness meditation interrupts communication between brain areas involved in processing pain sensations and areas that create a sense of separate self. During mindfulness meditation, pain signals still move from the body to the brain, but the individual does not feel as much ownership over those pain sensations—or attachment to them—so the pain and suffering are reduced.9
One example of a mindfulness-based practice designed specifically to help relieve pain is Shinzen Young’s Natural Pain Relief.
Qigong and Tai-Chi
Qigong and tai-chi are traditional Chinese body-mind practices involving gentle movements, attention to breath, and the cultivation of life-force energy. Numerous scientific studies have been conducted showing the physical and psychological benefits of qigong and tai-chi.
One of these benefits of qigong practice is the reduction of chronic pain, including chronic low back pain and spinal cord injury spasms. Qigong practice is an effective way of reducing neuropathic pain and spasms and helping people become more active.10
Like meditation, there are many different forms of qigong—with classes available in a wide variety of in-person and online venues.
Biofeedback Therapy
Biofeedback techniques help a person acquire voluntary control over normally automatic bodily functions, such as heart rate. During a biofeedback session, the individual is connected to electrical sensors that provide information about their body.
A biofeedback practice can help a person become aware of their physical responses to stress or pain—for instance, how their breathing might become more rapid or their muscles more tense. The individual can then learn specific techniques to prevent, reduce, or reverse these involuntary reactions when they are exacerbating pain. In this way, biofeedback can provide physical and emotional relief from chronic pain.
Acupuncture
Acupuncture is a technique associated with Chinese Medicine that involves inserting hair-thin needles at specific locations on the body to facilitate the balanced flow of life-force energy. According to Chinese Medicine, pain is often the result of a blockage or imbalance of life-force energy. When these imbalances are resolved, the pain will dissolve.
Multiple studies have demonstrated the safety and effectiveness of acupuncture in the treatment of chronic pain, including back pain, joint pain, and migraine headaches.11
Feldenkrais Method of Somatic Education
The slow, gentle exercises of a Feldenkrais practice can help expand awareness of physical sensations and explore new ways of moving. New ways of moving to create new neural pathways—new circuits in the brain. The new movements and new neural circuits, in turn, allow a person to experience moving without pain—because their nervous system hasn’t yet formed an association between the movement patterns and pain.
Once someone experiences new ways of moving without pain, they’re able to expand their pain-free movement capacity. The more their nervous system dissociates pain with movement, the less sensitive the nerves become. Over time, this allows them to move more with less pain, therefore breaking out of the chronic-pain cycle.
Restorative/Therapeutic Yoga
Restorative or therapeutic styles of yoga are another excellent way of reducing chronic pain without the use of opioid medications.
The Kaiut Method is one form of restorative yoga designed specifically to resolve chronic pain conditions by unwinding chronic restrictions in the joints. With comfort and safety, the joint stimulations within particular poses promote neurological reconnection between brain and body—reactivating neural networks that were lost due to injuries and traumas. The body regains its mobility, and chronic pains are gradually dissolved.
Pain Reprocessing Therapy
Pain reprocessing therapy is a system of psychological techniques that retrain the brain to interpret and respond properly to signals from the body to break the cycle of chronic pain. PRT works by rewiring neural pathways in the brain to deactivate pain.
In one clinical trial, 150 patients with mild or moderate back pain without a clear physical origin underwent four weeks of pain reprocessing instruction. After these four weeks of PRP sessions, two-thirds of the people were pain-free or nearly pain-free—and 98% of them experienced at least some improvement.12
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is a psychological modality that helps a person identify negative or unproductive thoughts, feelings, and behaviors—and replace them with more positive and beneficial ones. In CBT sessions, the individual learns to manage discomfort—including the discomfort of chronic pain—by shifting their focus and perspective.
This reframing of physical sensations and emotional responses can lessen the perceived intensity of pain. Instead of being caught in a negative feedback loop, the person can enjoy new and creative ways of thinking, feeling, and acting concerning pleasant, unpleasant, and neutral sensations.
Chiropractic Therapy
Chiropractic—another alternative to pain-relieving drugs—is a therapy that involves manipulating the spine (and other parts of the body’s boney structure) to restore spinal alignment, relieve pain, and improve function and range of motion. Correcting spinal alignment reduces pressure on the central nervous system, which increases the body’s innate capacity to heal itself and reduces chronic pain.
Network chiropractic—a more gentle and subtle form of chiropractic care—uses light touches along the spine rather than forceful adjustments. This improves nervous system communication with the rest of the body and releases any negative interference that might be causing pain.
Physical Therapy
Physical therapy (aka PT) is a well-known treatment modality that can help people experiencing chronic pain conditions regain strength and mobility—and reduce pain in the process. For instance, a physical therapist might suggest exercises to strengthen a person’s core muscles to help alleviate low back pain.
A physical therapist might also utilize techniques such as massage, TENS therapy (transcutaneous electrical nerve stimulation), or cold laser therapy to disrupt pain signals, increase blood flow for healing, flood-damaged cells with light energy, increase intracellular metabolism, and encourage the production of endorphins. All such interventions can help relieve chronic pain.
Myofascial Release Therapy
Myofascial release therapy is a form of deep-tissue massage that has shown great promise as an effective treatment for chronic pain. It goes deeper than a regular massage—working at the level of connective tissues rather than muscles. This therapeutic modality may be provided by an osteopath, chiropractor, physiotherapist, or massage therapist.13
Myofascial release therapy is designed to relieve pain in a person’s myofascial tissues—the thick connective tissues that support their muscles. This myofascial tissue is a network that spreads throughout the entire body, connecting muscles, joints, and bones; and providing support to the internal organs.
During myofascial release therapy, the therapist locates myofascial areas that feel rigid, stiff, or frozen—rather than fluid, elastic, and flexible. These are the places that are likely causing physical discomfort and, when released, can help reduce or eliminate chronic pain.
References
[1] Dahlhamer, James, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016. Centers for Disease Control and Prevention.
https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm
[2] Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95.
https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1.htm_w
[3] Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95.
https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1.htm_w
[4] Chou R, Deyo R, Devine B, et al. The effectiveness and risks of long-term opioid treatment of chronic pain. Evidence report/technology assessment no. 218. AHRQ publication no. 14–E005-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
[5] Opioid Use Disorder. Johns Hopkins Medicine.
https://www.hopkinsmedicine.org/health/conditions-and-diseases/opioid-use-disorder
[6] Safe and Responsible Use of Opioids for Chronic Pain: A Patient Information Guide. (October, 2018). U.S. Department of Veterans Affairs.
https://www.va.gov/PAINMANAGEMENT/Opioid_Safety/OSI_docs/10-791-Safe_and_Responsible_Use_508.pdf
[7] Krishnakumar D, Hamblin MR, Lakshmanan S. Meditation and Yoga can Modulate Brain Mechanisms that affect Behavior and Anxiety-A Modern Scientific Perspective. Anc Sci. 2015 Apr;2(1):13-19.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4769029/
[8] Cosio D, Demyan A. Behavioral Medicine: Applying Mindfulness-Based Stress Reduction for Comorbid Pain and PTSD. Pract Pain Manag. 2021;21(4).
[9] Mindfulness Meditation Reduces Pain by Separating It From the Self (July 8, 2022). Neuroscience News.
https://neurosciencenews.com/mindfulness-meditation-pain-20987/
[10] Morgan, Christine. Studies focus on the positive impact that Qigong has on reducing pain and enabling movement. University of Minnesota Medical School.
[11] Devitt, Michael (May 21, 2018). Research Finds Acupuncture Effective for Chronic Pain. American Academy of Family Physicians.
https://www.aafp.org/news/health-of-the-public/20180521acupuncture.html
[12] Yoni K. Ashar, Alan Gordon, Howard Schubiner, et al. (September 29, 2021). Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry. 2022;79(1):13-23.
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2784694
[13] Walters, Meg. (April 26, 2022). What Is Myofascial Release Therapy? LiveScience.
https://www.livescience.com/what-is-myofascial-release-therapy
