Non Opioid Treatment of Pain -

Non-Opioid Approaches to Chronic Pain Management

When selecting pharmacological treatments for chronic pain, combining different non-opioid medications often yields the best results. These medications work through various mechanisms in the pain pathway, targeting both peripheral and central nervous system pathways to alleviate discomfort.

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Physical Therapy

Acetaminophen

Meloxicam

Amitriptyline

Capsaicin

Gabapentin

Over-the-Counter Analgesics:

Acetaminophen: 650 mg every 6 hours (up to 3000 mg/day; limit to 2000 mg/day for patients with liver disease or those consuming three or more alcoholic drinks daily).
Naproxen: 500 mg every 12 hours, or 500 mg in the morning plus 250 mg twice daily (maximum 1000 mg per day).
Ibuprofen: 600 mg every 6 hours (maximum 2400 mg/day).

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs):

Meloxicam: 7.5 mg daily.
Salsalate: 1000 mg every 8 hours, or 1500 mg every 12 hours (maximum 3000 mg/day).
Piroxicam: 20 mg once daily.
Celecoxib: 100–200 mg twice daily.

Important: Patients over 65 or those with heart failure, liver disease, diabetes, or using nephrotoxic medications should have creatinine levels checked before starting NSAIDs and periodically during treatment.

Antidepressants:

Amitriptyline, start at 10-25 mg, titrate to 100 mg (max 50 mgif taking an SSRI/SNRI)*
Nortriptyline, start at 10-25 mg, titrate to 100 mg (max 50 mg if takingan SSRI/SNRI)*
Venlafaxine, start at 37.5 mg, titrate as needed up to 225mg QD
Duloxetine (60 mg QD) and/or Pregabalin (300-450 mg/day divided BID)

*Caution using Tricyclic Antidepressants in older adults (65+ years) or in patients on tramadol Patients receiving a tricyclic antidepressant (TCA) equivalent to 100 mg amitriptyline or 50 mg nortriptyline or 75 mg venlafaxine should have well-controlled blood pressure at baseline, and at recheck within the first two weeks. TCAs should not be used in patients 65 years or older.

Topical Pain Relievers:

Capsaicin: Available as a cream (0.025% or 0.075%) to be applied 3–4 times daily. Full benefit may take up to 8 weeks. An 8% capsaicin patch is available for a 60-minute application once a day.
Diclofenac: Gel form (1%) can be applied 2–4 grams up to 4 times daily. A 40-drop solution can be applied up to 4 times a day.
Lidocaine: Available as a cream (apply up to 4 times daily, maximum 300 mg/day) or patches (up to 3 patches for 12 hours within a 24-hour period).
Methyl Salicylate: Typically applied 3–4 times daily to the affected area.

Anticonvulsants (Anti-Epileptics):

Gabapentin: Increase dose gradually to 900–1200 mg three times daily.
Pregabalin: Start at 50 mg three times a day (150 mg/day total), with the option to increase based on effectiveness and tolerance.

Additional Non-Pharmacological Approaches:

Physical Therapy & Exercise: A regular exercise program can improve strength, flexibility, and overall well-being, helping to manage chronic pain.
Yoga and Acupuncture: These complementary therapies may provide pain relief by promoting relaxation and reducing muscle tension.
Massage Therapy: Manual therapy can enhance circulation, reduce muscle stiffness, and alleviate chronic pain.
Weight Loss: Reducing excess weight can reduce strain on joints and lower overall pain levels, especially in conditions like osteoarthritis.

Sources: Expert consensus and references from DailyMed and CDC guidelines on non-opioid treatments for chronic pain.