Non-Opioid/Non-Pharmacologic Pain Management Guide for Primary Care
Primary Care
(Adapted from University of Rochester Strong Memorial Hospital 2024 PolicyStat guidelines)
Purpose
Provide evidence-based guidance to individual providers and medical services to incorporate non-opioid/non-pharmacologic pain treatment options into individual practices, as well as to inform the development of service-specific pain management guidelines and bundles.
Main points
Review of multimodal treatment recommendations
Condition-specific non-opioid alternatives
Rural considerations
This guide was developed to support rural primary care clinicians as they manage their patients’ complex chronic pain. It discusses evidence-based non-opioid and non-pharmacologic treatment options that can be used in the treatment of chronic pain in the primary care setting.
Additionally, in the treatment of chronic pain please consider:
If feasible, partner with a larger medical center/hospital system to assist with complicated cases and/or a pain management specialist like a palliative care provider who will be available to answer specific questions.
Develop consistent protocols for all controlled substance medications, especially for ordering, monitoring, clinical documentation, and intervention parameters. This will help establish clear expectations for all patients and clinicians.
Utilize telehealth communication platforms to assist patients with transportation barriers.
Co-prescribe naloxone routinely for patients at high risk for opioid overdose, and offer to all patients who are prescribed opioids.
Avoid benzodiazepine-opioid combinations whenever possible.
Join a Project ECHO hub for pain management and behavioral health support.
Develop informal case-review groups with nearby clinicians.
Resources:
Substance Abuse and Mental Health Services Administration (SAMHSA) for rural grants and medications for opioid use disorder (MOUD) resources
Health Resources and Services Administration (HRSA) Rural Communities Opioid Response Program (RCORP) for grants and opportunities to collaborate with outside health centers
American Society of Addiction Medicine (ASAM) for clinical guidance
Providers Clinical Support System (PCSS) for free addiction training
Multimodal treatment recommendations
See the 2022 Centers for Disease Control and Prevention (CDC) Clinical Practice Guideline for a detailed summary of evidence to support non-opioid and non-pharmacologic approaches to pain management.
Listed below are stepwise approaches. They are also intended to be used in combination with opioids as needed:
Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) given around the clock (ATC) or as needed (PRN) if there are no opioid requirements
Adjunctive medications (e.g., topicals, neuropathic agents, skeletal muscle relaxers, disease-specific agents)
Nerve blocks and peripheral nerve stimulation (See our “Interventional Pain Management Care Options for Rural Primary Care Clinicians” guide.)
Additional considerations:
Frequent reassessment of acute pain is encouraged to identify when escalation in care should be considered.
Special populations
Patients taking medication for opioid use disorder (MOUD)
Patients who are pregnant or breastfeeding: Caution should be taken as many medications carry risks during pregnancy and breastfeeding. (Acetaminophen can be used in place of ibuprofen during pregnancy.)
Opioids should be used when the clinical scenario is appropriate.
Opioids should only be prescribed after clinical examination, diagnosis, pain and risk assessment, consideration of non-opioid/non-pharmacologic options, and review of state-specific prescription drug monitoring program (such as I-STOP in New York).
Screen for personal or family history of substance use disorder (SUD)/mental health disorder. Screen for high-risk factors for opioid-related adverse events.
See our other toolkit materials for opioid pain-management approaches and tapering guidelines for opioids and benzodiazepines.
Acute pain
The CDC recommends that non-opioid therapies are at least as effective as opioids for many common types of acute pain. Clinicians should maximize use of non-pharmacologic and non-opioid pharmacologic therapies as appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy.
Implementation considerations
Non-opioid therapies are at least as effective as opioids for many common acute pain conditions, including low back pain, neck pain, pain related to other musculoskeletal injuries (e.g., sprains, strains, tendonitis, and bursitis), pain related to minor surgeries typically associated with minimal tissue injury and mild postoperative pain (e.g., simple dental extraction), dental pain, kidney stone pain, and headaches including episodic migraine.
Please note in the tables below: Other therapies for these conditions may be appropriate; these are options that are supported by evidence reviews.
Non-pharmacologic therapies for acute pain conditions supported by clinical evidence reviews
Condition | Therapies |
|---|---|
Acute low back pain | Heat, spinal manipulation, acupuncture, massage |
Other acute musculoskeletal pain | Ice and elevation to reduce swelling, acupressure/acupuncture, transcutaneous electrical nerve stimulation (TENS), massage |
Acute neck pain with radiculopathy | Cervical collar or exercise |
Episodic migraine | Remote electrical neuromodulation |
Non-opioid pharmacotherapy for acute pain supported by clinical evidence reviews
Condition | Therapies |
|---|---|
Acute musculoskeletal injuries | Topical NSAIDs provide the greatest benefit-harm ratio, followed by oral NSAIDs or acetaminophen. |
Dental | NSAIDs more effective than opioids for surgical dental pain |
Kidney stone | NSAIDs more effective than opioids |
Low back pain | NSAIDs similarly effective to opioids for low back pain; skeletal muscle relaxants recommended by American College of Physicians |
Episodic migraines | Triptans, NSAIDs, antiemetics, dihydroergotamine, calcitonin gene-related peptide antagonists (gepants), and lasmiditan are associated with improved pain and function with usually mild and transient adverse events. |
Note: NSAID use has been associated with serious gastrointestinal events and major coronary events, particularly in patients with cardiovascular or gastrointestinal comorbidities, and clinicians should weigh risks and benefits of use, dose, and duration of NSAIDs when treating older adults as well as patients with hypertension, renal insufficiency, heart failure, or those with risk for peptic ulcer disease or cardiovascular disease. Vasoactive effects of triptans and ergot alkaloids might preclude their use in patients with migraine who also have cardiovascular risk factors.
Chronic pain
The CDC recommends that non-opioid therapies are preferred for subacute and chronic pain. Clinicians should maximize use of non-pharmacologic and non-opioid pharmacologic therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks to the patient.
Implementation considerations
Clinicians should recommend appropriate noninvasive non-pharmacologic approaches to help manage chronic pain, such as exercise (e.g., aerobic, aquatic, or resistance exercises) or exercise therapy (a prominent modality in physical therapy) for back pain, fibromyalgia, and hip or knee osteoarthritis; weight loss for knee osteoarthritis; manual therapies for hip osteoarthritis; psychological therapy, spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, and multidisciplinary rehabilitation for low back pain; mind-body practices (e.g., yoga, tai chi, or qigong), massage, and acupuncture for neck pain; cognitive behavioral therapy (CBT), myofascial release massage, mindfulness practices, tai chi, qigong, acupuncture, and multidisciplinary rehabilitation for fibromyalgia; and spinal manipulation for tension headache.
Please note in the tables below: While other therapies for these conditions may be appropriate, these are options that are supported by evidence reviews.
Non-pharmacologic therapies for chronic pain supported by clinical evidence reviews
Condition | Therapies |
|---|---|
Chronic back pain | Exercise; physical therapy; psychological therapy, specifically CBT and pain reprocessing therapy; spinal manipulation; low-level laser therapy; massage; mindfulness-based stress reduction; yoga; acupuncture; and multidisciplinary rehabilitation for low back pain |
Chronic neck pain | Mind-body practices (e.g., yoga, tai chi, or qigong), massage, and acupuncture |
Fibromyalgia | CBT, myofascial release massage, mindfulness practices, tai chi, qigong, acupuncture, and multidisciplinary rehabilitation |
Tension headache | Spinal manipulation |
Osteoarthritis, hip | Exercise therapy/physical therapy to reduce pain and improve function |
Osteoarthritis, knee | CBT, exercise therapy/physical therapy to reduce pain and improve function |
Temporomandibular disorder pain | Patient education, self-care, occlusal splints, biobehavioral therapy. |
Note: General approaches for subacute and chronic pain—exercise, mind-body interventions, and behavioral treatments (including CBT and mindfulness practices)—can encourage active patient participation in the care plan and help address the effects of pain in the patient’s life. These active therapies have somewhat more robust evidence for sustained improvements in pain and function than more passive treatments (e.g., massage), particularly at longer-term follow-up. In addition, physical activity can provide additional health benefits, such as preventing or reducing symptoms of depression.
Non-opioid pharmacotherapy for chronic pain supported by clinical evidence reviews
Condition | Therapies |
|---|---|
Osteoarthritis, one or a few joints near the surface | Topical NSAIDs |
Osteoarthritis, multiple joints or not controlled with topical | Duloxetine or systemic NSAIDs |
Chronic low back pain | Duloxetine or systemic NSAIDs |
Neuropathic pain | Tricyclic, tetracyclic, and serotonin-norepinephrine reuptake inhibitors (SNRI) antidepressants; selected anticonvulsants (e.g., pregabalin, gabapentin enacarbil, oxcarbazepine); and capsaicin and lidocaine patches. Evidence for capsaicin and lidocaine is limited. Use caution when prescribing tricyclic antidepressants in older adults due to risk of confusion and falls. |
Diabetic peripheral neuropathy | Duloxetine and pregabalin |
Postherpetic neuralgia | Pregabalin and gabapentin |
Fibromyalgia | SNRIs, NSAIDs (e.g., topical diclofenac), and specific anticonvulsants (i.e., pregabalin and gabapentin) are used to improve pain, function, and quality of life. |
Note: Oral NSAIDs should be used with caution, particularly in older persons and in patients with cardiovascular comorbidities, chronic renal failure, or previous gastrointestinal bleeding. In patients with gastrointestinal comorbidities but without current or previous gastrointestinal bleeding, cyclooxygenase-2 inhibitors or NSAIDs with proton pump inhibitors can be used to minimize risk compared with risk with use of NSAIDs alone.
Dosing recommendations
The tables below contain dosing recommendations for:
Baseline analgesia
General adjunctive medications
Adjunctive medications based on disease state
A: Baseline analgesia (all patients if no contraindication)
Medication | Class | Dose | Special considerations |
|---|---|---|---|
Acetaminophen | Non-opioid analgesic | 650–1000 mg (15 mg/kg) orally/rectally (PO/PR) 3–4 times daily | Reduce dose (650 mg PO 3–4 times daily): cirrhosis, chronic alcohol use, enzyme-inducing medications (e.g., phenobarbital), malnutrition Max 4000 mg (acute use)/3000 mg (long-term use)/day from all routes |
Ibuprofen | NSAID | 400–800 mg (10 mg/kg) PRN 3–4 times daily | Gastrointestinal (GI) bleeding risk: elderly, history of peptic ulcer disease, history of GI bleeding Cardiovascular event risk known cardiovascular disease or risk factors Renal injury risk: impaired renal function, dehydration, hypovolemia, heart failure, hepatic impairment, those taking diuretics and angiotensin converting enzyme inhibitors, and the elderly Pregnancy: contraindicated in the 3rd trimester |
Ketorolac
| NSAID | Oral only as continuation of intramuscular or intravenous therapy Weight ≥ 50 kg and < 65 years old: 20 mg once, followed by 10 mg every 4–6 hours as needed maximum daily dose (MDD): 40 mg (combined maximum 5 days due to significant GI bleeding risk) Weight < 50 kg or ≥ 65 years old: 10 mg every 4–6 hours as needed MDD: 40 mg (combined maximum 5 days due to significant GI bleeding risk) |
B: General adjunctive medications
Medication | Class | Indication | Dose | Special considerations |
|---|---|---|---|---|
Lidocaine | Topical analgesic | Localized pain | Up to 3 patches applied to the most painful area daily PRN Leave on 12 hours/remove for 12 hours | Formulations:
|
Gabapentin | Anticonvulsant | Neuropathic pain Post-injury pain Perioperative/ postoperative pain | 100–300 mg at bedtime or 100 mg 3 times daily, increase as tolerated every 2–3 days (max 3600 mg/daily in 3 divided doses) Single dose: 600–900 mg x 1, given the night before or 1–2 hours prior to surgery OR 600 mg the night before and 600 mg 2 hours before surgery | Misuse potential in patients with risk or documented SUD reported in 15–68% due to euphoric effects vs. 1.6% in general population Monitor for dizziness/sedation Reduce dose in renal insufficiency Postoperative pain management duration reported as single dose (strongest evidence) or 24–72 hours max |
Cyclobenzaprine | Skeletal muscle relaxant | Musculoskeletal pain | 10 mg PO every 8 hours PRN for muscle spasm | Misuse potential Anticholinergic: avoid in elderly |
C: Adjunctive medications based on disease state
Neuropathic pain
Medications should be added stepwise; combination therapy with two agents from different classes is common.
Medication | Dose |
|---|---|
Nortriptyline | Start at 10–25 mg at bedtime; increase every 3–7 days as tolerated (max 150 mg/day). |
Pregabalin | Start at 25–50 mg 3 times daily (max 600 mg/day in divided doses); reduce dose in renal insufficiency. |
Duloxetine | Start at 30 mg daily, titrate to 60 mg after 1 week if tolerated; avoid in creatinine clearance < 30 mL/minute. |
Venlafaxine | Start at 37.5 mg daily; increase by 37.5–75 mg weekly as tolerated (max 225 mg/day); reduce dose in renal insufficiency. |
Abdominal pain
Antiemetics (ondansetron, promethazine, prochlorperazine, haloperidol)
Medication | Dose |
|---|---|
Promotility (metoclopramide) | 10 mg (0.1 mg/kg/dose) PO every 6 hours PRN |
Haloperidol (cannabinoid hyperemesis) | 5 mg PO every 6 hours PRN for nausea/vomiting Reasonable first line option for nausea/vomiting with cannabinoid use |
Antispasmodic (dicyclomine) | 10–20 mg PO every 6 hours PRN |
Olanzapine oral dissolving tablet (ODT) (cannabinoid hyperemesis) | Adults: 10 mg ODT daily PRN |
Muscle relaxants
Medication | Dose |
|---|---|
Tizanidine | Start at 2 mg up to 3 times daily PRN; increase based on response and tolerability in 2–4 mg increments per dose (max 36 mg/day). Minimum of 1–4 days between dose increases. |
Renal colic
Medication | Dose |
|---|---|
Ibuprofen | 400–800 mg (10 mg/kg) PO 3–4 times daily |
Topicals
Medication | Dose |
|---|---|
Capsaicin 0.025% cream | Peripheral neuropathic pain: Up to 4 times daily PRN to painful area Cannabinoid hyperemesis: Apply sizeable amount to abdomen, leave on for 30 minutes for relief. Some patients may have difficulty tolerating burning sensation. |
Diclofenac 1% gel | Lower extremities: Apply 4 g (8 fingertip units, FTUs) to affected area 4 times daily PRN (max 16 g or 32 FTUs per joint/day). Upper extremities: Apply 2 g (4 FTUs) to affected area 4 times daily PRN (max 8 g or 16 FTUs per joint/day). Maximum total body dose: 32 g or 64 FTUs/day |
Authors
Marin Valentino, PharmD, BCCCP, CPP
References
Bannuru, R. R., Osani, M. C., Vaysbrot, E. E., Arden, N. K., Bennell, K., Bierma-Zeinstra, S. M. A., Kraus, V. B., Lohmander, L. S., Abbott, J. H., Bhandari, M., Blanco, F. J., Espinosa, R., Haugen, I. K., Lin, J., Mandl, L. A., Moilanen, E., Nakamura, N., Snyder-Mackler, L., Trojian, T., Underwood, M., … McAlindon, T. E. (2019). OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and Cartilage, 27(11), 1578–1589. https://doi.org/10.1016/j.joca.2019.06.011
Chou, R., Wagner, J., Ahmed, A. Y., Blazina, I., Brodt, E., Buckley, D. I., Cheney, T. P., Choo, E., Dana, T., Gordon, D., Khandelwal, S., Kantner, S., McDonagh, M. S., Sedgley, C., & Skelly, A. C. (2020). Treatments for acute pain: A systematic review (Comparative Effectiveness Review No. 240). Agency for Healthcare Research and Quality. https://www.ncbi.nlm.nih.gov/books/NBK566506/
Dowell, D., Ragan, K. R., Jones, C. M., Baldwin, G. T., & Chou, R. (2022). CDC clinical practice guideline for prescribing opioids for pain – United States, 2022. Morbidity and Mortality Weekly Report. Recommendations and Reports, 71(3), 1–95. https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w
Qaseem, A., McLean, R. M., O'Gurek, D., Batur, P., Lin, K., & Kansagara, D. L. (2020). Nonpharmacologic and pharmacologic management of acute pain from non-low back, musculoskeletal injuries in adults: A clinical guideline from the American College of Physicians and American Academy of Family Physicians. Annals of Internal Medicine, 173(9), 739–748. https://doi.org/10.7326/M19-3602
Singh, R. B. H., VanderPluym, J. H., Morrow, A. S., Urtecho, M., Nayfeh, T., Roldan, V. D. T., Farah, M. H., Hasan, B., Saadi, S., Shah, S., Abd-Rabu, R., Daraz, L., Prokop, L. J., Murad, M. H., & Wang, Z. (2020). Acute treatments for episodic migraine (Comparative Effectiveness Review No. 239). Agency for Healthcare Research and Quality. https://www.ncbi.nlm.nih.gov/books/NBK566246/
Skelly, A. C., Chou, R., Dettori, J. R., Turner, J. A., Friedly, J. L., Rundell, S. D., Fu, R., Brodt, E. D., Wasson, N., Kantner, S., & Ferguson, A. J. R. (2020). Noninvasive nonpharmacological treatment for chronic pain: A systematic review update (Comparative Effectiveness Review No. 227). Agency for Healthcare Research and Quality. https://www.ncbi.nlm.nih.gov/books/NBK556229/
U.S. Department of Health and Human Services (2019, May). Pain management best practices inter-agency task force report: Updates, gaps, inconsistencies, and recommendations. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf
