What are the options for non-narcotic (non-opioid) pain management?

From the Guidelines

Non-narcotic pain management should prioritize the use of nonopioid pharmacologic and nonpharmacologic therapies, such as acetaminophen, NSAIDs, and physical therapy, to minimize the risks associated with opioid medications. For acute pain, the most effective non-narcotic options include:

• Acetaminophen (Tylenol) at 650-1000mg every 6 hours (maximum 4000mg daily) 1
• NSAIDs like ibuprofen (Advil, Motrin) at 400-800mg every 6-8 hours with food (maximum 3200mg daily) or naproxen (Aleve) at 500mg initially, then 250mg every 6-8 hours (maximum 1250mg daily) 1
• Topical options such as diclofenac gel 1% applied to painful areas 4 times daily, lidocaine patches 5% worn for 12 hours daily, or menthol/capsaicin creams Non-pharmacological approaches are equally important and can include:
• Physical therapy
• Heat/cold therapy
• Massage
• Acupuncture
• Cognitive behavioral therapy
• Mindfulness meditation These methods work through various mechanisms, such as inhibiting inflammation, affecting central pain processing, and providing localized relief without systemic effects 1. The use of multimodal analgesia, combining different classes of analgesic medications and non-pharmacologic therapies, can lead to improved pain relief and reduced side effects. For example, the combination of acetaminophen and NSAIDs can reduce the need for opioids and improve postoperative outcomes 1. In cases where neuropathic pain is present, consider gabapentin starting at 300mg daily and gradually increasing to 300-600mg three times daily, or pregabalin starting at 75mg twice daily and increasing as needed 1. Ultimately, the goal of non-narcotic pain management is to provide effective pain relief while minimizing the risks associated with opioid medications, and a multimodal approach that incorporates both pharmacologic and non-pharmacologic therapies is often the most effective strategy.

From the FDA Drug Label

Patients were permitted up to 4 grams of acetaminophen per day as needed for pain, in addition to pregabalin. Patients were allowed to take opioids, non-opioid analgesics, antiepileptic drugs, muscle relaxants, and antidepressant drugs if the dose was stable for 30 days prior to screening. Patients were allowed to take acetaminophen and nonsteroidal anti-inflammatory drugs during the studies

The options for non-narcotic (non-opioid) pain management include:

• Acetaminophen: up to 4 grams per day
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Antiepileptic drugs: such as pregabalin
• Muscle relaxants
• Antidepressant drugs

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From the Research

Non-Narcotic Pain Management Options

• Acetaminophen is a first-line treatment option for mild to moderate pain, as it is well tolerated and effective 3, 4, 5, 6, 7
• Nonsteroidal anti-inflammatory drugs (NSAIDs) are also a first-line treatment option for mild to moderate pain, with topical NSAIDs recommended for non-low back, musculoskeletal injuries 3, 4, 6, 7
• Selective cyclooxygenase-2 NSAIDs are a more expensive treatment alternative that can be used to avoid the gastrointestinal adverse effects of nonselective NSAIDs 3, 4
• Adjunctive medications, such as muscle relaxants, may be added as appropriate for specific conditions if the recommended dose and schedule of first-line agents are inadequate 3, 4
• Tramadol is a useful therapy for patients who do not receive adequate pain relief with acetaminophen and are at risk for NSAID-related side effects 5
• Topical capsaicin is an effective analgesic for localized chronic pain associated with osteoarthritis 5
• Over-the-counter (OTC) analgesics, such as NSAIDs and acetaminophen, are safe and effective first-line options for managing acute pain, including dental pain and low back pain 6
• Combination medications, such as acetaminophen, aspirin, and caffeine, are effective for reducing migraine pain and other symptoms 6

Considerations for Non-Narcotic Pain Management

• Patient risk factors, such as gastrointestinal bleeding, cardiovascular disease, or chronic renal disease, should be considered when selecting a non-narcotic pain management option 3, 4
• The American College of Rheumatology recommends the use of topical NSAIDs and oral NSAIDs to treat arthritis pain, and conditionally recommends against the use of opioids 6
• The American Headache Society suggests that OTC NSAIDs and combination medications are Level A recommendations for reducing migraine pain and other symptoms 6
• The American Dental Association supports the use of nonopioid OTC analgesics, such as NSAIDs and the NSAID/acetaminophen combination, as first-line options for managing acute dental pain 6
• The American College of Physicians supports the use of NSAIDs as first-line therapy for the treatment of low back pain 6