New Jersey: Abuse of Prescription Opioids, 1 unitPage 7 of 9

5. Alternatives to Opioids for Pain Management

Opioids are associated with the potential risks of opioid-related adverse drug events (such as respiratory and gastrointestinal related events) and abuse or dependence, which can significantly increase the cost of medical care (Carter et al., 2020). For this reason, reducing opioid monotherapy,* and using nonopioid treatments, as well as complementary and alternative treatments, are important factors in the management of pain.

*Monotherapy: the use of a single drug to treat a disease or condition.

Reducing the Use of Opioids

Effective pain management should focus on avoiding opioid monotherapy and reducing the doses used to treat acute pain. This approach involves the administration of various opioid and non-opioid agents that act on different sites, resulting in a synergistic* and additive** effect. The goal is to reduce opioid-related adverse drug events and their costs, as well as reducing the risks of opioid abuse or dependence (Carter et al., 2020).

*Synergistic: combining the drugs leads to a larger effect than expected.

**Additive: Occurs when two or more drugs combine to produce an effect greater than effect of either drug taken alone.

Non-opioid pharmacologic therapies include acetaminophen and/or non-steroidal anti-inflammatory drugs (NSAIDs). When NSAIDs and/or acetaminophen are included in treatment regimens with opioids for pain relief, an opioid-sparing* effect has been demonstrated (Carter et al., 2020).

*Opioid-sparing: the use of drugs that allow a patient to feel a similar level of pain relief while taking fewer opioids.

Cannabis may also have an opioid-sparing effect, whereby a smaller dose of opioids provides equivalent analgesia when paired with cannabis. A growing number of studies involving patients who use cannabis to manage pain demonstrate reductions in the use of prescription analgesics along with favorable pain management outcomes. However, there is a lack of research from real-world settings exploring the opioid-sparing potential of cannabis among high-risk individuals who may be engaging in frequent illicit opioid use to manage pain (Lake et al., 2019).

Complementary and Integrative Approaches

A growing body of evidence suggests that complementary and integrative approaches can help manage some painful conditions. In fact, opioids may be less effective than nonopioid therapies for some acute and chronic pain conditions. Adding to the problem, opioids prescribed for surgery and other acute pain conditions often go unused, a potential source for diversion and misuse (AHRQ, 2020, January 2).

Complementary and integrative treatments include natural products such as vitamins, herbs, and probiotics; mind-body practices such as yoga, meditation, and naturopathy; and traditional Chinese medicine. At least 30% of the U.S. population uses complementary health approaches, most along with conventional treatments (Feinberg et al., 2018).

Research is lacking on demographic, lifestyle, and health-related factors for people using complementary health approaches for pain, and data is particularly sparse in underserved communities. Many of these communities have the highest rates of pain in the nation (e.g., arthritis), and have a rich anecdotal history of using natural products for pain management (Feinberg et al., 2018).

A 2017 review looked at which complementary approaches might be helpful for relieving chronic pain and reducing the need for opioid therapy. There was evidence that acupuncture, yoga, relaxation techniques, tai chi, massage, and osteopathic or spinal manipulation may have some benefit for chronic pain, but acupuncture was the only technique that reduced a patient’s need for opioids (NCCIH, 2021).

Research shows that hypnosis is moderately effective in managing chronic pain, compared to mainstream medical care. However, the effectiveness of hypnosis varies from one person to another (NCCIH, 2021).

Studies of mindfulness meditation for chronic pain showed that it is associated with a small improvement in pain symptoms. Studies have shown that music can reduce self-reported pain and depression symptoms in people with chronic pain (NCCIH, 2021).

Coverage of Nonpharmacologic Treatments

CDC’s 2016 Guideline for Prescribing Opioids for Chronic Pain recommended the use of nonopioid and nonpharmacologic therapies as first-line treatment for chronic pain. Consistent with other recent clinical practice guidelines, CDC also advises that if opioids are prescribed, they should be combined with nonpharmacologic and nonopioid therapies (Heyward et al., 2018).

An increasing volume of evidence and consensus demonstrates the benefits of many of these approaches in clinical practice. The use of nonopioid and nonpharmacologic therapies provides an opportunity to simultaneously improve the quality of care for those with pain while reducing overreliance on prescription opioids (Heyward et al., 2018).

Despite these recommendations, wide variation in insurance coverage of nonpharmacologic treatments remain. This may be driven by the absence of best practices, the administrative complexities of developing and revising coverage policies, and payers’ economic incentives. Healthcare providers have an opportunity to improve the accessibility of services, reduce opioid use, and ultimately improve the quality of care for individuals with chronic non-cancer pain while alleviating the burden of opioid addiction and overdose (Heyward et al., 2018).