Table 1.
Common non-opioid chronic pain management strategies.
| Strategy | Examples | Usual Dose Range | FDA Approved Chronic Pain Indications |
Significant Side Effects | Notes | |
|---|---|---|---|---|---|---|
| Multidisciplinary pain treatment | Johns Hopkins Hospital Pain Treatment Program | 3–4 weeks of intensive 5–7 days/week attendance at clinic | Not subject to FDA approval. Has been shown to improve any type of chronic pain, especially with no identifiable cause or where other approaches have failed. | None | Patient should be willing to decrease/stop opioid medications. Insurance coverage may not be available or require significant prior authorization process. | |
| Non-opioid medications | NSAID | aspirin | 325 to 650 mg every 4 h (Max 4 g/day) | Disorders of joint of spine, generalized pain, headaches, OA, RA | Bleeding, gastric ulcer, tinnitus, bronchospasm, and Reye’s syndrome | Should not take OTC aspirin for more than 10 days at a time without instruction from physician. |
| ibuprofen | 200 to 800 mg every 4–6 h (Max 3.2 g/day) | Generalized pain, headaches, OA, RA | Congestive heart failure, myocardial infarction, stroke, Stevens-Johnson syndrome, and hearing loss | Should not take OTC ibuprofen for more than 10 days at a time without instruction from physician. | ||
| naproxen | 250 to 500 mg every 12 h (Max 1 g/day) | Ankylosing spondylitis, bursitis, generalized pain, OA, RA | Congestive heart failure, myocardial infarction, stroke, Stevens-Johnson syndrome, bleeding, and renal failure | OTC naproxen can be taken for 6 months without instruction from physician. | ||
| Anti-depressants | duloxetine | 30 to 60 mg daily | Diabetic peripheral neuropathy, fibromyalgia, chronic musculoskeletal pain | May be fatal in overdose, suicidal ideation, Stevens-Johnson syndrome, myocardial infarction, liver failure, and serotonin syndrome | Cannot be stopped suddenly or may have withdrawal syndrome. Pain relief may take 4–6 weeks after achieving an effective dose. | |
| venlafaxine | 75 to 225 mg daily | None. | Hyponatremia, bleeding, hepatitis, seizure, suicidal thoughts, and serotonin syndrome | RCTs have demonstrated efficacy for neuropathic pain and prophylaxis of migraine/tension type headaches. Pain relief may take 4–6 weeks after achieving an effective dose. | ||
| nortriptyline | 50 to 100 mg daily | None. | Sudden cardiac death, SIADH, hepatic failure, stroke, suicidal thoughts, dizziness, and falls | Dosing should be guided by plasma blood level. RCTs have shown efficacy for neuropathic pain. Pain relief may take 4–6 weeks after achieving an effective dose. | ||
| Anti-epileptic drugs | gabapentin | 300 to 600 mg every 8 h | Post-herpetic neuralgia | Stevens-Johnson syndrome, hypoglycemia, sedation, suicidal thoughts, dizziness, and falls. Misuse and/or abuse of gabapentin has also been reported. | RCTs have also shown efficacy for diabetic peripheral neuropathy, and fibromyalgia. Pain relief may take 4–6 weeks after achieving an effective dose. | |
| pregabalin | 75 to 150 mg every 12 h (Max 450 mg/day) | Diabetic peripheral neuropathy, fibromyalgia, neuropathic pain from a spinal cord injury, post-herpetic neuralgia | Jaundice, suicidal thoughts, and acute renal insufficiency | Pain relief may take 4–6 weeks after achieving an effective dose. | ||
| Physical therapy (PT) | Exercise therapy | 8–12 PT sessions over 4–6 weeks | Not subject to FDA approval. Used to treat back and neck pain, arthritis, fibromyalgia | Worsening pain, new injury, myocardial infarction, and sudden death | Referral is needed. Patient needs to practice skills at home. Exercises are widely variable by therapists. | |
| Psychological therapies | CBT | Weekly hour-long individual sessions for 12 weeks | Not subject to FDA approval. Used for all types of pain. | None | Referral may be needed. Patients need to complete homework. Pain relief is only short-term. Not all therapists trained in pain CBT. | |
| MBSR | Weekly 2-h long group sessions for 8 weeks | Not subject to FDA approval. Used for all types of pain. | None | Optional 6-h retreat. Instructors for MBSR are not widely available. Pain improvement is short-term but can improve physical functioning for up to 26 weeks. | ||
| CAM | Acupuncture | 6–12 weekly sessions over 6–12 weeks | Not subject to FDA approval. Used to treat OA, chronic pelvic pain, chronic prostatitis, chronic neck pain, chronic back pain | Nerve injury causing worse pain and infection | Not always covered by insurance or available; no widely accepted protocol of acupuncture delivery; most studies performed outside USA | |
| Peripheral procedures | Trigger point injections | Lidocaine, corticosteroid, or “dry needling” | Single injection by physician. May be repeated. | Not subject to FDA approval. Used to treat chronic neck pain, headaches, iliac crest syndrome, and myofascial pain. | Nerve injury causing worse pain, infection, pneumothorax, seizure, and local tissue necrosis | Need to palpate location of maximum tenderness. Few long-term studies. Should be done with PT. |
| Intra-articular Injection | Sodium hyaluronate, corticosteroid | Single Injection by physician. May be repeated. | Not subject to FDA approval. Used to treat OA, RA, hip arthritis, low back pain, shoulder pain, TMJ, de Quervain’s tenosynovitis | Nerve injury causing worse pain and infection | 1–2 office visits. No clear evidence that these injections provide greater pain relief compared to sham procedures. | |
| Spinal procedures | Epidural steroid injection | Corticosteroid +/− local anesthetic (see nerve block for examples) | 1–3 injections separated by at least a month (no more than 3 injections in 12 months) | None. | Infection, bleeding, vertebral fracture (after multiple injections), paralysis, stroke, loss of vision and death. | Best results use fluoroscopic guidance. Multiple different procedures to enter epidural space. No clear evidence that these injections provide greater pain relief compared to sham procedures. |
| Nerve block | 0.25%-0.5% bupivacaine, 2% lignocaine, or 1% lidocaine | One diagnostic block and then second long-term nerve block (3–6 months pain relief). | Chronic radiculopathy, cancer- related, facet join degeneration | Nerve injury causing worse pain, infection, paralysis, and seizure | Outpatient surgical procedure. May repeat every 6–12 months as needed | |
| Radiofrequency denervation | 1–2 diagnostic nerve blocks followed by fluoroscopic guided destruction of nerve | Facet joint pain, low back pain with disc herniation, sacroiliac pain. | Nerve injury causing worse pain, infection, and paralysis | Outpatient surgery. May be repeated. Systematic reviews of trials have not shown significant benefit over sham. | ||
| Spinal cord stimulator | Insertion of temporary stimulator to determine efficacy and then insertion of permanent device | Chronic intractable pain of the trunk and/or limbs, pain associated with failed back surgery syndrome, complex regional pain syndrome | Nerve injury causing worse pain, infection, and paralysis | Pre-op psychological evaluation, at least two outpatient surgery visits, regular follow-up. Revisions may be necessary. | ||
| Surgery | Discectomy, spinal fusion | Back pain with nerve injury (e.g. disc herniation), spinal stenosis, | Failed back surgery syndrome, death, paralysis, and infection | Pre-op evaluation, surgery, +/− post-op hospital stay, usually 6 weeks off work, at least 3 month healing time, +/− PT |
NSAID = non-steroidal anti-inflammatory drugs; FDA = Food and Drug Administration; OTC = over the counter; CAM = complementary and alternative medicine; RCT = randomized clinical trials; CBT = cognitive behavioral therapy; MBSR = mindfulness based stress reduction; OA = osteoarthritis; RA = rheumatoid arthritis; SIADH = syndrome of inappropriate antidiuretic hormone secretion. These strategies are not mutually exclusive and can be combined as directed by a health care provider. Unfortunately, little information is known about the comparative effectiveness of these strategies.