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Typically prescribed to treat acute pain from an injury or surgery, opioids trigger the release of endorphins—the same feel-good neurotransmitters that are released after exercise, a great date or taking a bite of chocolate. They dampen the perception of pain and boost feelings of happiness and well-being.
But the relief they provide is temporary. When opioids wear off, the user may crave those good feelings again and want a way to get them back. This is how opioid addiction starts. The more a person takes, the more their body acclimates, requiring an even higher dose to achieve the same levels of relief.
In essence, pain management is the root cause of the opioid epidemic. In an effort to curb what some consider to be an overprescription problem in America, many patients and providers are now seeking non-opioid alternatives for pain management. So what non-opioid alternatives are out there? We dug into the research and spoke with some experts on the topic to learn more about non-opioid treatments for chronic pain.
What is chronic pain and central sensitization?
Chronic pain affects tens of millions of Americans and often goes deeper than just back, knee or neck pain. In fact, it can actually change the way that the brain and the nervous system processes pain, resulting in chronic pain syndrome, or central sensitization.
Chronic pain can start with trauma or injury, fibromyalgia, cancer, arthritis or even just poor lifestyle or postural habits. After the pain turns chronic, which can occur anywhere between three-to-six months, the nervous system becomes so used to sending pain signals to the brain that it may continue to do so, even after the damaged or inflamed tissue has healed.
Experiencing a constant sensation of pain can condition the nervous system to persistently run on high, lowering the threshold for pain and other kinds of discomfort—things like fatigue, dizziness, nausea and sensitivity to temperature, touch and sound. These symptoms may grow worse and lead to depression and anxiety as the brain’s chemical balance shifts, according to Dr. Matthew Crooks of Pinnacle Pain and Spine.
Due to the many ways central sensitization affects the body, it’s often necessary to address the physical, emotional, behavioral and chemical aspects. With that in mind, opioids are not the answer to true recovery. And since everyone’s body is different, some patients’ return to health might include multiple types of treatments.
As we begin to explore alternative options, we rounded up some of the most common and successful non-opioid pain management options out there. Consider the following seven.
7 Non-opioid alternatives for pain management
Physical therapists are experts in chronic pain. They can help patients identify the causes of their pain and even aid in prevention of future pain. Physical therapy can be prescribed by any specialist doctor or general practice providers. Appointment frequency will vary depending on the severity of a patient’s situation, from several times a week to every other week or even once a month for those who are primarily dealing with prevention.
This steady schedule of appointments can help patients form strong relationships with their physical therapists, helping them feel supported and hopeful. Grant Kaper, DPT, TPS at Physical Therapy Orthopedic Specialists, believes this encouragement is crucial in cases of chronic pain, maintaining that the nonphysical aspects of healing can be even more important than the physical ones.
Physical therapists use a variety of modalities for chronic pain treatment. Some of these include strength and flexibility exercises, posture awareness, body mechanics instruction, biofeedback and manual therapy.
Dr. Kaper, for example, focuses on chronic pain treatment based on current neuroscience research and primarily uses manual therapy and movement as modalities for healing. These movements have been shown to increase blood flow to the tensioned nerves allowing for decreased sensitivity and improving mobility in seconds. Manual therapy allows positive shifts and is able to reverse some of the central sensitization.
He also uses movement to improve blood flow and healing. Dr. Kaper considers aerobic exercise to be the gold standard, adding that after a six-mile run, the body of a healthy adult produces an effect equivalent of consuming ten milligrams of morphine.
But even with that in mind, reintroducing movement can be very challenging for an individual dealing with chronic pain. Dr. Crooks recognizes that the longer the pain has gone on, the harder it is to be active. A physical therapist can help individuals determine a plan of graduated movement to help facilitate healing.
Injections and nerve blocks
People who are seeking a temporary relief for chronic pain may find what they’re looking for with injections and nerve blocks. This temporary relief can help the patient pursue more intensive physical therapy and movement, or even simply empower them to resume their normal life activities.
Injections and nerve blocks are often recommended for people who have already tried some physical therapy and anti-inflammatories, according to Dr. Kavita Sharma at Manhattan Pain and Sports Associates. Most pain doctors and anesthesiologists provide the following types of injections.
Trigger point injections are best for patients who have already tried physical therapy, according Dr. Sharma. Trigger points are knots that form in a persistently tense muscle and can cause centralized or radiating pain. That’s where the pain doctor or anesthesiologist will insert the needle and inject a mixture of an anesthetic and a steroid. This relief—typically from pain caused by fibromyalgia, tension headaches or myofascial pain—can last anywhere from a few weeks to several months.
Steroid injections are considered a viable option for patients with knee or shoulder pain who saw little success from more conservative treatments. This treatment, which includes an injection that contains only a steroid, is delivered by the same process as trigger point injections, and it’s considered much more focused and effective than oral steroids. Steroid injections may also be appropriate for tendonitis and rheumatoid arthritis in conjunction with other treatment methods.
Nerve blocks are performed for muscle spasms or nerve pain. They’re intended to block specific nerves after being injected around nerve clusters, using fluoroscopy as a visual guide. They frequently consist of a local anesthetic and, in many cases, a steroid. Nerve blocks typically last a few days, though the anesthetic can ward off the pain longer.
Acupuncture is an ancient Chinese practice that is used to stimulate the nervous system by inserting small needles into specific points on the body, providing relief from pain and nausea while promoting overall well-being. In all the research on acupuncture out there, there is no conclusive evidence that explains why acupuncture works, but Dr. Chris Tomshack, CEO of HealthSource Chiropractic, has seen firsthand the positive impact it can have on so many patients’ lives and bodies.
Many western practitioners believe that the nerve, muscle and tissue stimulation that happens during acupuncture boosts the body’s natural painkilling ability. During an acupuncture session, a practitioner will take an inventory of your symptoms and consider where they should insert the needles for maximum benefit. The hollow needles cause very little, if any, pain when inserted, says Dr. Tomshack.
After anywhere from to five to 20 needles are inserted, the patient will relax for 15 to 20 minutes. Some practitioners will twirl the needles, or apply heat, cold or mild electrical pulses to them during this time.
Radiofrequency neurotomy—also referred to as a radiofrequency ablation—may be a good option for those with back, neck, knee and hip pain that hasn’t subsided through use of medications or physical therapy, and for whom surgery is not an option. This treatment method uses heat generated by radio waves to target specific nerves, temporarily turning off their ability to send pain signals.
Performed as an outpatient procedure, the patient will receive medication through an IV to keep them comfortable throughout the procedure, as well as numbing injections before the radiofrequency needles are inserted. Like with a nerve block, the doctor will use a fluoroscope in order to target the precise nerve tissue that needs to be treated.
After the procedure is complete and the patient has had time to rest, they can resume other forms of treatment, such as physical therapy. Once the pain is deadened by the radiofrequency, relief can last anywhere from six to 18 months, providing patients with enough time to improve mobility and function. This, in turn, can relieve the pain once the ablation wears off, according to Dr. Crooks.
Spinal cord stimulation
Spinal cord stimulation is not for every kind of pain. Dr. Sharma recommends this type of treatment for patients who have sciatic-type symptoms even after spine surgery and a series of epidural injections. For patients with shooting arm or leg pain, it’s something of a last resort that can prove to be particularly helpful, according to Dr. Sharma.
Spinal cord stimulation uses a pacemaker-like device that replaces the pain with a different sensation like a tingling or massage-like feeling that the patient can turn on and off based on their pain levels. Newer forms may replace with the pain with an alternate sensation for those that find the sensation uncomfortable.
For this reason, before the device is implanted surgically, patients try a five- to seven-day trial period, wearing the stimulator on a belt. If the stimulator reduces the pain by 50 percent or more, decreases the amount of pain meds needed throughout the day or improves daily function, the patient and provider can talk about surgery to implant the device into the skin.
This method has helped patients with sciatic pain, chronic pain from trauma, stump pain, sclerosis, spine surgery pain and reflex sympathetic dystrophy.
Since pain is received in the brain, conscious breathing or meditation has been shown retrain the mind, changing the sensation of pain in a more lasting way than treatment of the spine or a back massage.
When the brain is intensely focused on one area, such as the area of inflammation and pain, the brain reacts more strongly and notices threats more acutely than usual. “[This] increases the perception of pain, turning up the volume on the alarm system,” according to Dr. Amy Baxter, CEO and Founder of Pain Care Labs. When the individual in pain can focus on something else, whether that is distraction, mindfulness or hypnosis, the sensation of pain will lessen.
Since most chronic pain begins with inflammation, many pain doctors recommend an anti-inflammatory diet, even after the pain has been relieved. Changing one’s lifestyle is the best way to improve and prevent inflammation and chronic pain, according to Dr. Tomshack.
Chronic inflammation is the root of several serious illness, including heart disease, many cancers and Alzheimer’s disease. And while stress, lack of exercise and genetics can all contribute to inflammation, diet is a major factor that patients can control completely.
The anti-inflammation diet is different from other conventional diets in that its purpose is not to lose weight, but rather to provide the body with flavonoids, carotenoids, antioxidants, micronutrients and anti-inflammatories.
Dr. Andrew Weil, lifestyle and aging expert, provides several general tips for an anti-inflammatory diet:
- Aim for variety in food groups and individual components
- Eat as much fresh food as possible
- Minimize consumption of processed foods
- Eat an abundance of fruits and vegetables
While diet alone may not fix all that ails a patient, these adjustments can reduce inflammation and, in turn, pain. This makes it an option worth exploring for anyone dealing with chronic pain.
Want to help bring relief?
While working to decrease opioid addition is important, there are still going to be patients seeking respite from chronic pain. Thankfully, there are many non-opioid alternatives worth exploring. While all of the above options have strong proponents of their effectiveness, physical therapy remains one of the best routes to addressing the root causes of pain.
The good news for anyone who wants to help people manage their pain is that physical therapist assistants are in demand—employment of PTAs is projected to grow 30 percent by 2026, according to the Bureau of Labor Statistics.* Curious if you’d be a good fit for a physical therapist assistant career? Check out our article, “7 Signs You Should Consider Becoming a Physical Therapist Assistant.”
*Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, [information accessed September 25, 2018] www.bls.gov/ooh/. Information represents national, averaged data and include workers at all levels of education and experience. Employment conditions in your area may vary.