Rhode Island: Substance AbusePage 9 of 12

7. Alternatives to Prescription Opioids for Pain Management

Opioids are associated with the potential risks of opioid-related adverse drug events, (e.g., respiratory and gastrointestinal related events) and abuse or dependence (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.

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 regarding 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 conditions in the nation, including 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, 2020).

Research shows that hypnosis is moderately effective in managing chronic pain when compared to usual medical care. However, the effectiveness of hypnosis varies from one person to another. Mindfulness meditation for chronic pain is associated with a small improvement in pain symptoms and music can reduce self-reported pain and depression symptoms in people with chronic pain (NCCIH, 2020).

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 a simultaneous opportunity to improve the quality of care for those with pain while reducing overreliance on prescription opioids (Heyward et al., 2018).

Despite CDC’s recommendations, wide variation in insurance coverage of nonpharmacologic treatments hampers the use of complementary and alternative options for pain management. 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 noncancer pain while alleviating the burden of opioid addiction and overdose (Heyward et al., 2018).