What you need to know

• Current CDC guidance recommends non-opioid medications and non-drug therapies as first-line treatment for most chronic pain — not because opioids never have a role, but because the evidence for them in long-term, non-cancer pain is much weaker than once thought.
• Effective chronic pain management usually combines several approaches at once: a non-opioid medication (or two), structured movement and physical therapy, behavioral support, and sometimes targeted procedures.
• When opioids are part of the plan, the principles are clear — lowest effective dose, shortest reasonable duration, regular reassessment, and naloxone available at home in case of overdose.

Chronic pain — pain that lasts longer than 3 months — is one of the most common reasons adults see a doctor. It includes ongoing back pain, joint pain from arthritis, nerve pain from diabetes or shingles, fibromyalgia, headache disorders, and many others. For decades, the standard was to layer pain medications on top of one another and reach for opioids when other options ran out. The understanding now is more nuanced. Long-term opioid therapy for chronic non-cancer pain has clear risks (dependence, overdose, falls, hormonal effects, paradoxical worsening of pain) and the evidence for sustained benefit is surprisingly thin.

The good news is that the menu of effective alternatives has expanded substantially. CDC’s 2022 clinical practice guideline emphasizes maximizing non-opioid therapies as first-line for chronic pain, with opioids reserved for situations where benefits are likely to outweigh risks. Most people end up with a combination plan — and the combination usually works better than any single intervention.

This article is a general overview. Specific conditions like osteoarthritis and persistent back pain have their own dedicated treatment approaches that are worth reading alongside this.

Non-drug therapies that genuinely work

Non-pharmacologic treatments are not “alternative” to medication in any soft sense — they are first-line, evidence-based interventions, and for many people they outperform medications over the long term.

Movement and physical therapy

For most chronic musculoskeletal pain (back, neck, knee, hip, fibromyalgia), supervised physical therapy and graded exercise are among the most effective interventions available. The instinct to rest hurts more than it helps in most chronic pain conditions; deconditioning makes everything worse, while progressive movement strengthens supporting muscles, improves joint function, and changes the way the nervous system processes pain. The right starting point depends on the condition — a physical therapist familiar with chronic pain can build a program that works around limitations rather than fighting them.

Cognitive and behavioral approaches

Cognitive behavioral therapy (CBT) for chronic pain is one of the best-studied interventions in this space. It does not “treat the pain in your head” — it teaches practical skills for managing pain, reducing the disability and distress that come with it, and breaking the cycle in which fear of pain leads to less activity, which leads to more pain. Mindfulness-based stress reduction (MBSR) and acceptance and commitment therapy (ACT) have similar evidence bases. These can be delivered in person or through reputable apps.

Other non-drug options with evidence

• Acupuncture has reasonable evidence for chronic low back pain, knee osteoarthritis, neck pain, and tension-type and migraine headaches.
• Massage therapy helps short-term for several musculoskeletal conditions and is low-risk.
• Yoga and tai chi combine gentle movement, balance, and breathing — strong evidence for low back pain and fibromyalgia.
• Heat and cold have small but useful effects for many conditions and minimal downside.
• Sleep work matters — poor sleep amplifies pain, and pain disrupts sleep. Treating one usually helps the other.

Stress reduction is its own lever — chronic stress raises systemic inflammation and lowers the threshold at which pain registers. Recognizing how stress shows up in the body is part of practical pain management.

Non-opioid medications

Several medication classes are effective for chronic pain — often more so than opioids over the long term, and with much smaller risk profiles.

NSAIDs and acetaminophen

Over-the-counter NSAIDs (ibuprofen, naproxen) and prescription NSAIDs (celecoxib, meloxicam, diclofenac) are workhorses for inflammatory and musculoskeletal pain. They have real long-term cautions — stomach ulcers and GI bleeding, kidney injury (especially in older adults or people with kidney disease), and modestly raised blood pressure and cardiovascular risk — so they are not free of risk, but at appropriate doses they are an effective foundation. Acetaminophen is a milder option with fewer GI and cardiovascular concerns; the main caution is cumulative liver effects, particularly in heavy alcohol users or people exceeding 3,000 to 4,000 mg per day.

Antidepressants used for pain

A small number of antidepressants treat pain through pathways separate from their mood effects. Duloxetine (Cymbalta), an SNRI, is FDA-approved for chronic musculoskeletal pain (including chronic low back pain), diabetic neuropathy, and fibromyalgia. Tricyclic antidepressants (amitriptyline, nortriptyline) at low doses help neuropathic pain, fibromyalgia, and chronic tension-type headaches. Both classes are recommended in the CDC guideline for specific chronic pain conditions.

Gabapentinoids

Gabapentin (Neurontin) and pregabalin (Lyrica) work best for neuropathic pain — diabetic neuropathy, postherpetic neuralgia after shingles, fibromyalgia, and certain chronic radicular pains. They are less effective for typical mechanical back pain or arthritis pain, despite being commonly prescribed for those. Side effects include drowsiness, dizziness, and weight gain; they require dose adjustment in kidney disease.

Topicals

Topical medications can work effectively for localized pain with minimal whole-body exposure.

• Topical NSAIDs (diclofenac gel, sold over the counter as Voltaren in the US) are particularly useful for hand and knee osteoarthritis, with much lower systemic absorption than oral NSAIDs.
• Topical lidocaine (creams, patches) is useful for localized neuropathic pain such as postherpetic neuralgia.
• Topical capsaicin depletes pain-signaling chemicals in nerve endings; some people get good relief, though the burning sensation in the first weeks is unpleasant.

Other options

Muscle relaxants (cyclobenzaprine, methocarbamol, baclofen) have a limited role for short-term flares of muscle spasm but are not effective long-term treatment for chronic pain. Cannabis-based medications have a growing literature with mixed results — some benefit for certain neuropathic and cancer pain conditions, with notable downsides including sedation. Newer agents like suzetrigine, a non-opioid sodium channel blocker, have entered the field but have so far been studied primarily for acute pain.

Procedural and interventional options

When medications and conservative treatment are not enough for localized pain, targeted procedures sometimes help.

• Joint injections — corticosteroid injections into a painful joint (knee, shoulder, hip) can reduce inflammation for weeks to months. Hyaluronic acid injections are another option for knee osteoarthritis.
• Trigger point injections for myofascial pain syndromes.
• Epidural steroid injections for nerve root pain from disc problems or spinal stenosis — modest, time-limited benefit for most.
• Radiofrequency ablation of pain-transmitting nerves, particularly for facet joint pain in the spine.
• Spinal cord stimulation — implanted devices that deliver mild electrical signals to interfere with pain transmission, used for severe refractory neuropathic pain.

Procedures are most useful as part of a broader plan, not as standalone fixes. Stacking shots without addressing the underlying conditioning, posture, or movement patterns rarely produces durable results.

When and how opioids fit

Opioids still have roles. They are effective for severe acute pain (after major surgery, with major trauma, with kidney stones), for cancer pain, for end-of-life care, and in selected cases of severe chronic pain that has not responded to anything else. The change in approach is about how they are used, not about banning them.

Current best practice principles for opioid prescribing in chronic pain include:

• Non-opioid options tried first and continued alongside any opioid that is added.
• The lowest effective dose for the shortest reasonable duration. Higher doses (above roughly 50 morphine milligram equivalents per day, and especially above 90) carry substantially higher overdose risk for limited additional benefit.
• Goals defined upfront — pain rating alone is a poor measure; functional goals (walking distance, sleep, activity) tell the better story.
• Regular reassessment, typically every 1 to 3 months, with willingness to taper down or off if benefits are not clear.
• No combining with benzodiazepines or other CNS depressants except in unusual circumstances.
• Naloxone available at home for overdose reversal — recommended for anyone on chronic opioid therapy.
• Avoiding abrupt discontinuation. Tapers should be gradual, often 10% per month or slower for someone who has been on opioids for a long time.

Tramadol and codeine sit in a middle zone — milder opioids with their own risks (drug interactions and unpredictable metabolism are particular concerns with codeine; serotonin effects and seizure risk with tramadol). They are not consequence-free alternatives.

When to see a doctor

Talk to a clinician about pain that has lasted longer than a few weeks despite reasonable self-care, that is interfering with sleep or daily activities, or that is not responding to over-the-counter measures. New severe pain, or pain accompanied by red flags — fever, unexplained weight loss, weakness, numbness, loss of bowel or bladder control — warrants prompt evaluation rather than home management.

If you are already on long-term opioids and feel they are no longer helping or that side effects outweigh benefits, that is a conversation to have with your prescriber rather than something to navigate alone. Tapering needs to be gradual to avoid withdrawal, and the supports around tapering — non-opioid medications, physical therapy, behavioral health — can make the difference between a successful taper and a struggle.

Frequently asked questions