A patient’s trauma history, mental health, family, and social situation all can affect the perception of pain. This is why chronic pain is described as a bio-psycho-social phenomenon. Without addressing those behavioral issues, opioid management of chronic pain will not provide the level of relief the patient is seeking, and dose escalation, with its concomitant morbidity and mortality, will often occur.
Studies show that opioids are only moderately successful in relieving pain and, in fact, are inferior to sleep restoration, mindfulness training, and physical exercise in providing long-term benefit.
Treatment Comparisons
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| Treatment | Reduction in Pain Intensity |
| Physical fitness | 30–60% |
| CBT/Mindfulness | 30–50% |
| Sleep restoration | 30–40% |
| Opioids | <30% |
| Tricyclics | <30% |
| Anti-epileptics | <30% |
| Cannabis | 10–30% |
| Acupuncture | >10% |
Source: David Tauben, MD, Chief of Pain Medicine at the University of Washington.
Non-Opioid Treatment Options
The following list shows various non-opioid treatment options, including behavioral, movement, and pharmacological treatments. This is not meant to be an exhaustive list but, rather, is intended to show the many empowering ways our patients can use readily accessible resources to help manage their pain.
Patient Lifestyle
- Healthy sleep management
- Weight reduction
- Diet/Nutrition
- Stress reduction
- Exercise
Physiotherapy Interventions
- Functional therapies
- Physical therapy (PT)
- Occupational therapy (OT)
- Passive modalities
Behavioral Interventions
- Educational groups
- Preventive
- Support
- Peer-to-peer/Living Well workshops
- Shared medical appointments
- Psychotherapy
- Individual counseling
- Group therapy
- Cognitive behavioral therapy
- Supportive care
- Case management
- Substance-abuse treatment
- Residential
- Outpatient
- Medication-assisted treatment referral
- Trauma-informed care
- PTSD screening
- Domestic violence screening
- Child abuse screening
Medical Interventions
- Non-opioid medications that may aid in chronic pain management
- NSAIDS, acetaminophen
- Tricyclic antidepressants (neuropathic pain)
- Anti-epileptics (neuropathic pain)
- Topical medications
- Minimally invasive surgical procedures
- Nerve blocks, steroid injections
- Interventional treatments: ablations, restorative injections, stimulators, implantable devices
- Surgical treatment
- Complementary and alternative treatments
- Manipulative therapy
- Acupuncture
Behavioral Treatment Options
Cognitive behavioral therapy (CBT)
› What is CBT? CBT is a form of psychotherapy that emphasizes the importance of the causal relationship between our thinking and our feelings and behaviors. The cognitive, or thinking part of our experience, very much affects the behavioral, or action part of our experience. With training, we can change the way we think to affect the way we feel and behave, even if the situation has not changed. CBT has an educational focus and teaches rational self-counseling skills.
› What does the research say about CBT for the treatment of chronic pain? Studies show that a patient’s report of chronic pain intensity is far more about that individual’s capacity to manage his or her pain than it is about stimulation of nociceptors.26 Additional studies show that patients experience between 30% to 60% reduction in pain intensity by learning and applying CBT techniques. This compares favorably to the estimated efficacy of 30% for chronic opioids.
› What are some of the key components of CBT for patients with CNCP? In general, CBT for chronic pain works to reduce patients’ pain, distress, and pain behavior while improving their daily functioning. Components of CBT may include helping patients to decrease negative emotional responses to pain and perceptions of disability while increasing their acceptance of pain as well as orientation toward self-management. CBT helps patients change the way they relate to pain so they can experience life more fully.
› What is the goal of CBT for patients with CNCP? Two fundamental concepts are at play in this strategy. One is that a person must accept the aspects of the pain that cannot be changed, including all the difficult thoughts, feelings, and bodily sensations that come with it. The second is that this acceptance allows for the possibility of the patient opening to the pain and committing to acting in ways that make the patient feel vital and energized. Learning to accept pain to live life is often referred to as “victory by surrender.”
Living Well with Chronic Pain
This program is one of a group of validated syllabus-based programs developed at Stanford University for the purpose of empowering individuals living with chronic pain. It is available in many communities around the country and teaches self-management skills concerning the management of chronic diseases, including pain.
Shared medical appointments
One approach for a busy practice to incorporate peer support, education, and behavioral treatment into the office visit is to use a shared medical appointment. The prescriber and a facilitator, often a nurse, can meet with patients as a group to discuss common issues, while simultaneously taking individual patients aside for brief patient-specific evaluations. Many insurance companies will pay for this treatment approach.
Peer-to-peer meetings
Trained peer educators can facilitate groups of pain patients to share successes, set goals, and help overcome common obstacles. Peer educators can work under the auspices of a licensed practitioner or enroll patients independently. Such programs can work in parallel with the other modalities mentioned in this section.
