Pain Management without Narcotics
Updated: May 14, 2021
There are a number of reasons the clinician should be familiar with non-pharmacologic methods for pain control. Our current opioid crisis may be the most pertinent, but also because some clients can’t tolerate pharmaceutical pain relief, or it may be contraindicated due to other medications, conditions, or their work responsibilities. Other clients simply choose to avoid pharmaceuticals altogether, and want a more natural approach. Acupuncture, has been proposed as the most evidence-based, non-pharmacologic treatment option for pain control (Fan, Miller, Bolash, McDonald & Faggert et al., 2017).
Acupuncture is considered a safe, effective, and cost-effective treatment for a variety of chronic and acute pain types, and is recommended by numerous federal regulatory agencies as the first line treatment for pain prior to prescribing opiates. The Veterans Administration and various branches of the U.S. Military have already demonstrated successful implementation of acupuncture in place of opiates for pain management. Evidence is strongest for its use with back pain, neck pain, shoulder pain, chronic headache, and osteoarthritis (Fan, Miller, Bolash, McDonald & Faggert et al., 2017, p 412). Acupuncture has shown to be more effective for pain #osteoarthritis than muscle-strengthening exercise, weight loss, and aerobic exercise (Fan, Miller, Bolash, McDonald, & Faggert et al., 2017).
The American College of Physicians published guidelines in 2017 specific to low back pain and recommended #acupuncture, along with superficial heat, massage or spinal manipulation, and NSAIDs or muscle relaxants for acute or subacute pain. Acupuncture was also recommended for chronic low back pain, in addition to exercise, multidisciplinary rehabilitation, mindfulness-based stress reduction, Tai Chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, and spinal manipulation (Fan, Miller, Bolash, McDonald, & Faggert et al., 2017, p 413).
Studies have demonstrated acupuncture superior to use of muscle relaxants, steroids, and NSAIDs for sciatica. A prospective, randomized trial of acupuncture versus morphine to treat acute onset, moderate to severe pain in patients presenting in the emergency room demonstrated acupuncture more effective and faster than analgesia, and even better tolerated (Grissa, Baccouche, Boubaker, Beltaief, & Bzeouich et al., 2016). Another systematic review found acupuncture second in overall effects only to biological agents, but superior to all other inventions including opioids. Interestingly, acupuncture has also shown to be effective for plantar heel pain, allergic rhinitis, knee osteoarthritis, tension-type headache, chemotherapy-induced and post-operative nausea and vomiting, and post-operative pain (Fan, Miller, Bolash, McDonald, Faggert et al., 2017). Evidence for its possibility of positive outcome for other etiologies is quite an exhaustive list that goes far beyond this post. Nonetheless, clinicians in the United States rely heavily on opioids, in spite of their risks, while underutilizing alternatives such as acupuncture (Fan, Miller, Bolash, McDonald, & Faggert et al., 2017).
Acupuncture has not demonstrated itself as a modality which offers significant pain relief for women in labor (Fan, Miller, Bolash, McDonald, & Faggert et al, 2017), but intradermal sterile water injections has proven both effective and safe for both mom and fetus (Koyucu, Demirci, Yumru, Salman, & Ayanoglu et al., 2018). Women who utilize this modality are still able to move without increased risk for fall, and their fetus is not sedated, at risk of respiratory distress, or neurologic depression. The risk and cost of the epidural however, is significant in comparison. The association between epidural and cesarean has posed a significant risk to childbearing women, whereas sterile water injections may offer an improved vaginal birth success rate (Koyucu, Demirci, Yumru, Salman, & Ayanoglu et al., 2018).
Importantly, women are overwhelmingly satisfied with the relief offered by the sterile water papules, although at the point of administration, pain can be significant. The vast majority would opt for this pain relief modality in subsequent childbirth scenarios. An important point, is that this technique is available for administration by nurses, without need for practitioner oversight, and accessible in community-based births, even delaying or preventing transfer to the hospital. The analgesic effect can last up to 120 minutes, which is especially advantageous for births in countries where access to hospital birth is limited (Koyucu, Demirci, Yumru, Salman, & Ayanoglu et al., 2018).
Pain is Both Physical & Emotional
Pain is intensely complex, encompassing both biological and psychological components. Ignoring this reality when treating clients with pain leads to incomplete treatment. Behavioral therapy for pain management can address the overlap between emotion and acute, or even chronic pain. Those with anxiety and depression alongside chronic pain have demonstrated the most severe pain and pain-related disability. Further, research suggests that pain may be exacerbated by unresolved psychological trauma (Dahlke, Sable, & Andrasik, 2017).
Therapy specific to emotional health is essential, as well as management for any underlying psychological conditions. Nonpharmacologic therapies which enhance emotional regulation include cognitive behavioral therapy, #yoga, biofeedback, and meditation. Their beneficial effect may be explained in understanding that both physical pain and emotion overlap their neural pathways among common structures in the brain. Both types of information contribute to our subjective experience and ultimately, our response to it (Dahlke, Sable, & Andrasik, 2017).
Emotional pain can mimic certain aspects of physical pain with regards to their brain activity and pain perception, such that social rejection activates the same areas of the brain as physical pain. One intriguing study found that the administration of acetaminophen daily compared to placebo reduced social pain. Awareness of the nature and location of the pain stimulus is not the only component of our experience, but also our emotional response, our subjective interpretation, and ultimately, our coping behavior. Addressing these areas can change our affective experiences (DeWall, MacDonald, Webster, Masten, & Baumeister et al., 2010).
Behavioral therapy has been a modality of mental health disorders, but yoga, meditation, biofeedback and cognitive behavioral therapy are increasingly being utilized for pain treatment. Changing thought processes within the brain can then alter the experience of pain (DeWall, MacDonald, Webster, Masten & Baumeister et al., 2010, p 159). Mindfulness meditation has been shown to improve headache pain and reduce anticipatory anxiety of pain (DeWall, MacDonald, Webster, Masten & Baumeister et al., 2010).
Evidence is mounting that treatment relying solely on pharmacotherapy is unsafe and often ineffective for chronic pain. Consensus recommendations are increasingly appreciating the role of a multi-modal treatment strategy. Physical therapy, cognitive behavioral therapy, mindfulness-based stress reduction, acupuncture, yoga, chiropractic treatment and a plethora of additional complementary modalities, including sterile water papules, have demonstrated effectiveness while offering few risks. The challenge often is coordinating these resources for clients who have limited financial and transportation resources. However, no specific contraindication for any of these modalities exist. Educating clients on their effectiveness is an important part of success. Support from family and friends is also important for success, as well as encouragement within the client/provider relationship.
Dahlke, L. A. M., Sable, J. J., & Andrasik, F. (2017). Behavioral therapy: emotion and pain, a common anatomical background. Neurol Sci, 38(1), 157-161. doi: 10.1007/s10072-017-2928-3
DeWall, C. N., MacDonald, G., Webster, G. D., Masten, C. L., Baumeister, R. F., Powell, C., Combs, D., Schurtz, D. R., Stillman, T. F., Tice, D. M., & Eisenberger, N. I. (2010). Ac etaminophen reduces social pain: behavioral and neural evidence. Psychol Sci, 21(7), 931-937.
Fan, A. Y., Miller, D. W., Bolash, B., Bauer, M., McDonald, M., McDonald, J., Faggert, S., He, H., Li, Y. M., Matecki, A., Camardella, L., Koppelman, M. H., Stone, J. A. M., Meade, L., & Pang, J. (2017). Acupuncture’s role in solving the opioid epidemic: evidence, cost- effectiveness, and care availability for acupuncture as a primary, non-pharmacologic method for pain relief and management - white paper 2017. Meridians: The Journal of Acupuncture & Oriental Medicine, 15(6), 411-425. doi: 10.1016/S2095-4964(17)60378-9
Grissa, M. H., Baccouche, H., Boubaker, H., Beltaief, K., Bzeouich, N., Fredj, N., Msolli, M. A., Boukef, R., Bouida, W., & Nouira, S. (2016). Acupuncture verses intravenous morphine in the management of acute pain in the ED. American Journal of Emergency Medicine, 34(11), 2112-2116.
Koyucu, R. G., Demirci, N., Yumru, A. E., Salman, S., Ayanoglu, Y. T., Tosun, Y., & Tayfur, C. (2018). Effects of intradermal sterile water injections in women with low back pain in labor: a randomized, controlled, clinical trial. Balkan Med J, 35, 148-154. doi: 10.4274/ balkanmedj.2016.0879