From the Guidelines
The most effective alternatives to opioids for chronic pain management are gabapentinoids, such as gabapentin and pregabalin, and serotonin-norepinephrine reuptake inhibitors (SNRIs), such as duloxetine, which have been shown to provide significant pain relief with minimal risks. When considering alternatives to opioids, it is essential to prioritize nonpharmacologic and nonopioid pharmacologic therapies, as they have been shown to be effective in managing chronic pain with fewer risks 1. For neuropathic pain, the evidence supports first-line use of gabapentinoids (gabapentin 300-1200mg TID or pregabalin 150-600mg daily in divided doses) and SNRIs like duloxetine (60-120mg daily) 1. Some key points to consider when selecting alternatives to opioids include:
- The importance of individualized treatment approaches, as efficacy varies by pain condition and patient characteristics 1
- The need to consider the potential risks and benefits of each treatment option, including the risk of gastrointestinal and cardiovascular adverse effects with NSAIDs 1
- The role of nonpharmacologic therapies, such as exercise and cognitive-behavioral therapy (CBT), in managing chronic pain 1
- The potential benefits of combining nonpharmacologic and nonopioid pharmacologic therapies to achieve optimal pain relief 1. Overall, the goal of chronic pain management should be to provide the greatest benefits relative to risks, and to prioritize treatments that have been shown to be effective and safe in the long term 1.
From the FDA Drug Label
NSAID medicines are used to treat pain and redness, swelling, and heat (inflammation) from medical conditions such as: different types of arthritis menstrual cramps and other types of short-term pain Aspirin is an NSAID medicine but it does not increase the chance of a heart attack Some of these NSAID medicines are sold in lower doses without a prescription (over-the-counter). NSAID medicines that need a prescription Generic Name Trade Name Celecoxib Celebrex® Diclofenac Cataflam®, Voltaren®, ArthrotecTM (combined with misoprostol) Diflunisal Dolobid® Etodolac Lodine®, Lodine® XL Fenoprofen Nalfon®, Nalfon® 200 Flurbiprofen Ansaid® Ibuprofen Motrin®, Tab-Profen®, Vicoprofen®* (combined with hydrocodone), CombunoxTM (combined with oxycodone) Indomethacin Indocin®, Indocin® SR, Indo-LemmonTM, IndomethaganTM Ketoprofen Oruvail® Ketorolac Toradol® Mefenamic Acid Ponstel® Meloxicam Mobic® Nabumetone Relafen® Naproxen Naprosyn®, Anaprox®, Anaprox® DS, EC-Naproxyn®, Naprelan®, Naprapac® (copackaged with lansoprazole) Oxaprozin Daypro® Piroxicam Feldene® Sulindac Clinoril® Tolmetin Tolectin®, Tolectin® DS, Tolectin® 600
The alternatives to opioids in the pharmacologic management of chronic pain syndromes include:
- NSAIDs: such as naproxen, ibuprofen, and celecoxib, which can be used to treat pain and inflammation.
- Anticonvulsants: such as pregabalin, which can be used to treat neuropathic pain. It is essential to note that the choice of alternative therapy should be based on the individual patient's needs and medical history, and should be made in consultation with a healthcare provider 2, 3.
From the Research
Alternatives to Opioids for Chronic Pain Management
Alternatives to opioids for the pharmacologic management of chronic pain syndromes include:
- Simple analgesics such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) 4
- Tricyclic antidepressants, tramadol, gabapentin, duloxetine, or pregabalin for neuropathic pain 4
- Cyclobenzaprine, pregabalin, duloxetine, or milnacipran for fibromyalgia 4
- Topical analgesics such as capsaicin, lidocaine, or salicylates for localized neuropathic or arthritic pain 4, 5
Non-Pharmacologic Therapies
Non-pharmacologic therapies can also be effective in managing chronic pain, including:
- Exercise and cognitive-behavioral therapy (CBT) 6
- Multicomponent programs that incorporate non-pharmacological therapies such as psychological therapies, meditation, physical exercise, and healthy habits 7
- Non-invasive and non-pharmacologic treatments such as physical therapy, occupational therapy, and acupuncture 8
Topical Therapies
Topical therapies can offer a safe and effective alternative to systemic therapies for chronic, localized musculoskeletal and neuropathic pain, including: