From the Guidelines
For pain management alternatives to capsaicin cream and diclofenac that aren't NSAIDs or opioids, consider duloxetine (Cymbalta) at 30-60mg daily, as it has been shown to achieve significant reductions in pain outcomes for patients with osteoarthritis, according to a systematic review by Chen et al 1. This medication works by modulating pain signals and can be used to treat neuropathic pain.
- Other alternatives include:
- Acetaminophen (Tylenol) at 325-650mg every 4-6 hours, not exceeding 3000mg daily, which inhibits pain signals in the central nervous system without the anti-inflammatory effects or stomach irritation of NSAIDs.
- Topical lidocaine patches (Lidoderm 5%) or creams (4-5%) that provide localized pain relief for 12 hours by blocking nerve signals.
- Counterirritants like menthol or camphor creams (such as Biofreeze or Icy Hot) that create cooling or warming sensations to distract from pain.
- Anticonvulsants such as gabapentin (starting at 300mg daily and gradually increasing) or pregabalin (Lyrica, 75-150mg twice daily) that are particularly useful for nerve pain.
- Non-pharmacological approaches such as physical therapy, acupuncture, and TENS units can also be used alongside these medications for comprehensive pain management, as recommended by the 2020 VA/DoD Clinical Practice Guideline for the Non-Surgical Management of Hip & Knee Osteoarthritis 1. It's worth noting that the most recent and highest quality study, published in 2022, recommends the use of duloxetine and pregabalin for the treatment of neuropathic pain, and duloxetine for the treatment of fibromyalgia 1.
From the Research
Alternatives to Capsaicin Topical Cream and Diclofenac
Some alternatives to capsaicin topical cream and diclofenac that aren’t NSAIDs or opioids include:
- Lidocaine, which has been shown to be useful in the treatment of postherpetic neuralgia, diabetic peripheral neuropathic pain, and complex regional pain syndrome 2, 3
- Ketoprofen gel, which has been shown to be effective in reducing pain in patients with knee osteoarthritis and acute musculoskeletal pain 4, 5
- Topical salicylate, which has been shown to be effective in treating chronic pain conditions, although the evidence is limited 4
- Other topical NSAIDs, such as ibuprofen and piroxicam, which have been shown to be effective in treating acute musculoskeletal pain 4, 5
Key Findings
- Topical lidocaine has been widely studied and found to reduce pain in patients with postherpetic neuralgia and diabetic peripheral neuropathic pain 3
- Ketoprofen gel has been shown to be superior to placebo and similar to oral celecoxib in reducing pain in patients with knee osteoarthritis 2
- Topical salicylate has been shown to be effective in treating chronic pain conditions, although the evidence is limited 4
- Formulation of topical diclofenac plays a part in its effectiveness, with gel formulations providing the best effects 6
Efficacy and Safety
- Topical NSAIDs, including diclofenac and ketoprofen, have been shown to be effective in providing pain relief in acute and chronic musculoskeletal pain, with minimal adverse events 4, 5, 6
- Lidocaine has been shown to be safe and effective in reducing pain in patients with postherpetic neuralgia and diabetic peripheral neuropathic pain 3
- Topical salicylate has been shown to be safe, although the evidence is limited 4