Below are a collection of recommendations from various sources^1-6 around alternatives to opioids and adjunctive therapy.

• Non-opioid selection based on pain type¹. Non-opioid dosing should generally be maximized before opioids are used.
  • General Pain: acetaminophen or NSAIDs
  • Neuropathic pain: tricyclics, gabapentin, duloxetine, pregabalin, topicals (lidocaine patches, capsaicin, salicylates)
  • Fibromyalgia: tricyclics, cyclobenzaprine, SNRIs (duloxetine, venlafaxine, milnacipran, etc.), pregabalin
• Chronic pain is often accompanied by impaired function, multiple medical conditions, and psychological disorders. All these areas should be addressed.^2,3
• Cognitive-behavioral therapy is the best-studied psychological intervention and has been shown effective for chronic pain.^2,3
• Integrate exercise and supervised therapy for stretching, strengthening, and cardiovascular conditioning.^2,3
• Proper sleep hygiene is recommended.³
• To prevent constipation, ensure patients are taking a stool softener plus a stimulant laxative (e.g., senna two tablets twice daily or bisacodyl 5 mg at bedtime plus docusate 100 mg to 200 mg daily).⁴
• Make small, infrequent dose adjustments in the elderly, in patients with renal or hepatic impairment, and in patients with other medical conditions. For example, patients with sleep apnea or lung disease may be at risk of respiratory depression.²
• Opioids may also make continuous positive airway pressure (CPAP) less effective.⁵
• For patients taking concomitant acetaminophen, such as in a combination product, watch for unintentional overdose. An FDA advisory committee has discussed limiting the total daily acetaminophen dose to 2,600 mg to reduce the risk of liver injury.⁶
• Risk factors for unintentional opioid overdose include renal or hepatic impairment, sleep apnea, sleep disorders, chronic obstructive pulmonary disease, cognitive impairment, or use of fentanyl, methadone, or long-acting opioid formulations.^2,5