Powerful pain relief: Options beyond opioids

August 22, 2018 Swedish Health Team

middle-aged woman wearing pink cancer head scarf, raising her arms to flex her muscles

  • [7 MIN READ]

    In this article:

  • There are many non-opioid pain relievers, including other medications, behavioral medicine and active therapy treatment approaches. 

  • These treatments can be combined to treat each patient’s specific chronic pain needs.

  • Swedish Pain Services offers a range of services for patients, including injection therapies, non-opioid medications, addiction management, and pain management programs.

While opioid medications may be valuable tools for carefully-monitored patients to use to help better manage their pain, the increased use of opioids to treat pain has seen a parallel increase in adverse effects including addiction, overdose and death.

News of the opioid epidemic has shed new light on additional strategies to more comprehensively help patients manage their pain and improve their function. These methods can be combined in customized ways to treat your specific pain problems. Steven Stanos, D.O., medical director of Pain Services at Swedish, outlines the most common non-opioid ways to treat pain.

Non-opioid medications

These medicines can play different roles in a tailored comprehensive pain treatment plan. “When we treat a person with chronic pain, we focus not only on pain score from zero to 10, but how pain has impacted one’s function, mood, quality of life and sleep,” Dr. Stanos says. “Different types of medications are used to target specific chemicals in the body that help to decrease pain, improve mood and restore quality sleep. This targeted approach of using different medications at different mechanisms in the body can be described as rational polypharmacy.

“Fear, depression, anxiety, maladaptive thoughts and other psychological factors significantly impact how we perceive and respond to pain,” Dr. Stanos continues. “Many patients with chronic pain may also struggle with insomnia or poor quality of sleep. A comprehensive medication plan for chronic pain focuses on not only analgesia or reducing pain but targeting medications to help improve psychosocial functioning and restorative sleep via various chemical and receptor targets in the body's nervous system.” 

There are six main types of non-opioid medications.

Anti-inflammatories, such as ibuprofen, target anti-inflammatory chemicals. These kinds of medications help patients with arthritis or joint trauma. Most of these medicines are prescription strength, although lower-strength anti-inflammatories and topical analgesics can also be found in over-the-counter formulations.

Antidepressants have been used for many years because they can help with the depression and anxiety that may be experienced by people who suffer from chronic pain. Antidepressants may help to block pain signals in the nervous system, providing an additional pain-relieving effect.

Anticonvulsants are commonly prescribed to treat different types of nerve pain. The most common ones are gabapentin and pregabalin. These medicines are approved by the U.S. Food and Drug Administration for some specific nerve pain conditions, as well as for widespread pain like fibromyalgia. Pain is decreased by the drug’s ability to decrease a specific type of calcium in the nervous system.

Topical analgesics are anti-inflammatory patches or gels that are mostly approved for joint or arthritis pain. This category also includes numbing medications like lidocaine patches, which are used for nerve pain and placed over the painful skin area.

Muscle relaxers are commonly prescribed to ease pain by decreasing muscle spasms. The most frequently used ones are tizanidine and cyclobenzaprine.

Sleep medications are commonly used to help decrease the time to fall asleep or help patients wake up less often. Common medications include tricyclic and tricyclic-like antidepressants such as amitriptyline, nortriptyline and trazodone or non-habit-forming sleep aids, including zolpidem. Many of the anticonvulsants used for pain relief such as gabapentin or pregabalin may also cause sedation that can also be used to improve sleep. Most of the sleep medications are approved for other conditions by the FDA but used “off-label” due to these additional benefits.

As with any medication, you should follow your physician’s dosage instructions carefully.

“A lot of these other medicines, even over-the-counter anti-inflammatories, can cause serious side effects, including stomach upset and bleeding, heart attacks, and kidney damage,” Dr. Stanos says. “Like opioid pain relievers, the anti-inflammatories and other medications have to be carefully monitored. Patients should also know exactly what medicines they are taking — the name, why they are taking it and what the goal of it is.”

Dr. Stanos adds that you should let your health care provider know if you are taking any additional medications since many may have potential for serious drug interactions and harm.  

Patients on chronic opioid therapy who are no longer benefiting from them or have developed an addiction disorder can benefit from medication-assisted treatment (MAT). MAT includes the use of medications like buprenorphine or methadone that patients can transition to or start on after detoxification from traditional opioids. Addiction medication management is supervised by a board-certified addiction medicine specialist.

Active therapy

Active therapy generally focuses on physical therapy, occupational therapy and exercise. If you are struggling with knee pain, for instance, you could benefit from working with a physical therapist (PT) to learn exercises to strengthen the muscles around your painful knee joint to help decrease pain. The therapist could assess how you walk, make modifications and start you on an aerobic exercise program as part of your individualized treatment plan. A PT can also educate you about your condition.

Occupational therapy is focused on patient function. “Occupational therapists (OTs) assess how a patient is functioning — their ergonomics and body mechanics — and teach pacing and other compensatory strategies,” Dr. Stanos says. “They may show patients how to adapt a certain activity to make it easier on their joints. In other situations, an OT may focus on more specific impairments of the upper limb, including wrist and hand conditions such as carpal tunnel syndrome."

He adds, "OTs may help rehabilitate persons with neurologic injuries such as those suffering from weakness and loss of function after a stroke. Here, the focus is on helping patients maximize function and improving how patients perform their activities of daily living.” At Swedish Pain Services, the occupational therapy program incorporates mind-body treatments like tai chi, helping patients use movement to help improve balance and stability and decrease pain and stress.

Behavioral health and mind-body interventions

Chronic pain often impacts a person’s mood. Patients can struggle with depression, anxiety, excessive worry and stress related to their pain condition. A behavioral medicine professional (e.g., a pain psychologist, social worker or counselor), as well as your pain physician, can help assess those psychological and social issues contributing to your pain. 

Treatment may address maladaptive thoughts and reactions to pain, helping patients learn better coping strategies and address other cognitive and behavioral issues. In addition to cognitive behavioral therapy, mindfulness-based stress reduction interventions and meditation may also be valuable tools a therapist can use to help patients shift their focus, feel more empowered to manage pain and control stress.

Relaxation training or biofeedback is another valuable behavioral health intervention that can be incorporated into your treatment program. A trained relaxation therapist instructs patients on how to relax and calm the body down with the help of deep breathing, imagery and other techniques.

Interventional procedures

Image-guided injection procedures are commonly used for acute and chronic back and neck pain. Real-time X-ray guidance helps the pain medicine physician correctly and safely place needles close to specific areas of the spine to deliver numbing medicine or steroids along damaged tissue or nerves to help decrease pain. This can include epidural steroid injections along an inflamed nerve related to a painful disc herniation and blocking nerves to specific spinal structures like facet joints, to name a few. The use of ultrasound guidance may be used in a similar fashion to help inject medications into large or small joints or tendons in the body, such as shoulders, knees, wrists and ankles. 

Putting it all together: Swedish’s Functional Restoration Programs

Swedish offers innovative “mini boot camps” for pain management called the Structured Functional Restoration Program. At this comprehensive level, patients participate in individual or in group sessions for five hours a day, three days a week, over a four-week period. Organized into groups of four, patients participate in one-hour sessions of physical therapy, occupational therapy, pain psychology and relaxation training.

There is also a pain management curriculum taught by a Swedish nurse educator covering important topics about pain physiology, stress, diet, sleep hygiene, pain medicine pharmacology and medication side effects. Physicians also see patients each week where they assess medication use, sleep and mood, clarify and answer questions patients may have regarding their condition or treatment, and help coordinate their program and follow-up plan.

Patients usually undergo a comprehensive, two-hour evaluation to determine their fitness for the program, where they are evaluated by the pain psychologist and pain medicine specialist.

“The focus of our pain rehabilitation programs is to combine different interventions where patients are given multiple tools to better manage their pain and improve their function,” Dr. Stanos says, “The group dynamic helps to bring patients together in an environment where they share their experience — and learn from each other’s experience — as they take on a more active role in their self-management. It creates an interesting milieu with patients from different backgrounds with interesting perspectives. Besides traditional physical therapy, pain education and psychological counseling, they participate in groups for yoga, tai chi and aerobic conditioning. The overarching goal is to help patients become more active, understand their pain and its impact on their life, and integrate techniques to decrease stress in the body.”

The structured program also gives the physicians time to individually adjust and taper pain medications and other medications to help with mood and improve sleep. Dr. Stanos says, “The evolution of pain management is moving towards more team-based and integrative models. We are happy to be integrating pain rehabilitation into our other state-of-the-art traditional methods of pain care.”

Find a doctor

If you have questions about pain management, contact Pain Services at Swedish. We can accommodate both in-person and virtual visits.

Whether you require an in-person visit or want to consult a doctor virtually, you have options. Swedish Virtual Care connects you face-to-face with a nurse practitioner who can review your symptoms, provide instruction and follow up as needed. If you need to find a doctor, you can use our provider directory.

Join our Patient and Family Advisory Council.

Additional resources 

Read our Pain Management Guide and learn more about relaxation techniques to manage chronic pain.

Providers turn cautious on painkillers

Fibromyalgia: How you can cope with a painful disease

Sleeping well despite chronic pain

This information is not intended as a substitute for professional medical care. Always follow your health care professional's instructions.

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