‍How to Relieve Chronic Pain Without Opioids

Chronic pain - pain that lasts longer than three months - affects roughly one in four US adults (24.3%), based on CDC NCHS 2023 surveillance data. For many of those adults, opioids were once a default. Today, both the 2022 CDC opioid guideline and most specialty guidelines recommend non-opioid approaches as preferred for most chronic pain - not because pain is being dismissed, but because better-evidenced options exist.

This guide surveys five categories of non-opioid options that have peer-reviewed evidence for specific chronic pain conditions: non-opioid medications, movement and rehabilitation, procedural and manual therapies, mind-body and brain-based approaches, and lifestyle support. Each section names the population the evidence applies to, because what works for chronic low back pain is not the same as what works for diabetic nerve pain or fibromyalgia.

Key Takeaways

• The 2022 CDC guideline recommends non-opioid therapies as preferred for most non-cancer, non-palliative chronic pain in outpatient adults.
• Several non-opioid medications - including duloxetine, certain antidepressants, gabapentinoids, and topical agents - have FDA-approved or guideline-supported uses for specific chronic pain conditions.
• For chronic low back pain specifically, the American College of Physicians' 2017 ACP LBP guideline recommends non-pharmacologic treatments - including exercise, acupuncture, mindfulness-based stress reduction, yoga, and cognitive behavioral therapy - as first-line.
• Brain-based therapies - including CBT, ACT, mindfulness-based programs, EAET, and Pain Reprocessing Therapy - have evidence within their specific studied populations and target the nervous-system processes that maintain pain after tissue has healed.
• Patients on long-term opioid therapy should not stop or change their medication without clinician guidance - abrupt discontinuation carries its own risks and the CDC guidance is explicit on this.

Why Non-Opioid Approaches Matter for Chronic Pain

Acute pain - the sharp signal you get from touching a hot stove - is the nervous system doing its job: warning the body of tissue damage. Chronic pain is different. After three or more months, tissue has typically healed, but the pain alarm can stay active. Research on chronic back pain has shown brain shifts in chronic pain - pain-related activity moves to emotional and motivational circuits over the chronification process - meaning the experience of long-standing pain is being driven by different mechanisms than the original injury. Lin Health publishes a chronic pain brain explainer for patients who want a deeper read on this.

Opioids work primarily on acute nociceptive pain pathways. For chronic pain that is being maintained by altered central nervous system processing - what the International Association for the Study of Pain has formally recognized as nociplastic pain - opioids are often a poor mechanistic match. They also carry well-documented long-term risks including dependence, opioid-induced hyperalgesia, falls, and overdose, all reviewed in the 2022 CDC opioid guideline.

This is the clinical reasoning behind the broader shift toward non-opioid options - not that opioids have no role, but that the evidence supports starting with, and often staying with, alternatives for most chronic pain. For more on how chronic pain changes nervous-system processing, see Lin Health's central sensitization explainer.

Non-Opioid Medications With Evidence for Chronic Pain

Medication is still part of the answer for many people - just not opioid medication. Several drug classes have peer-reviewed evidence for specific chronic pain conditions. Each has its own scope and side-effect profile.

NSAIDs and acetaminophen

NSAIDs (ibuprofen, naproxen, diclofenac, others) have evidence for some chronic pain conditions, particularly osteoarthritis and inflammatory pain. Acetaminophen has a more limited evidence base for chronic pain. Both carry meaningful long-term risks: NSAIDs are associated with gastrointestinal, renal, and cardiovascular adverse events, per the 2020 AHRQ review. Long-term use should be discussed with a clinician.

SNRIs - duloxetine

Duloxetine, a serotonin-norepinephrine reuptake inhibitor, is FDA-approved for chronic musculoskeletal pain (chronic low back pain and knee osteoarthritis), fibromyalgia, and diabetic peripheral neuropathic pain. The strongest controlled-trial evidence is in diabetic peripheral neuropathy, supported by a Cochrane review (Lunn et al., 2014). For fibromyalgia, a Cochrane review on SNRIs (Welsch et al., 2018) found a clinically relevant benefit for ≥30% pain reduction with duloxetine and milnacipran versus placebo, with no clinically meaningful effect on quality of life or fatigue and higher rates of treatment discontinuation due to adverse events. FDA approval for chronic musculoskeletal pain rests on randomized trials in chronic low back pain (Skljarevski et al., 2010) and knee osteoarthritis (Chappell et al., 2009).

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Tricyclic antidepressants

Tricyclic antidepressants such as amitriptyline have evidence for some neuropathic pain conditions, per the 2015 amitriptyline Cochrane review (Moore et al.). Side effects - anticholinergic effects, sedation, cardiac considerations - limit use, especially in older adults.

Gabapentinoids

Gabapentin and pregabalin have peer-reviewed evidence for postherpetic neuralgia and diabetic peripheral neuropathy specifically, per Cochrane gabapentinoid reviews (Wiffen 2017; Derry 2019). These drugs are commonly prescribed off-label for other chronic pain conditions, where evidence is weaker.

Topical lidocaine and capsaicin

Topical agents - lidocaine patches and high-concentration capsaicin - have evidence for localized neuropathic pain such as postherpetic neuralgia, per the 2017 capsaicin Cochrane review (Derry et al.). They are non-systemic, which is a meaningful safety advantage.

Low-dose naltrexone (off-label)

Low-dose naltrexone (LDN) has been studied for fibromyalgia and some other chronic pain conditions. Early pilot trials (Younger et al., 2014) suggested benefit in fibromyalgia, but two more recent moderate-sized randomized double-blind trials - a 2023 placebo-controlled crossover trial in fibromyalgia (Bested et al., n=58, Pain Reports) and the 2024 Lancet Rheumatology trial (Bruun et al., n=99, women with fibromyalgia, 6 mg LDN) - did not find LDN superior to placebo on the primary pain outcome. Some secondary outcomes (e.g., proportion of participants with ≥30% pain reduction; memory) favored LDN in the 2024 trial. LDN is not FDA-approved for chronic pain. The evidence base is mixed - early small trials suggested benefit, larger trials have not yet confirmed it on primary outcomes - and any off-label use should be weighed by a clinician. Lin Health has a deeper write-up on low-dose naltrexone for pain for readers exploring this option.

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Movement and Rehabilitation

For chronic low back pain - the most common chronic pain presentation in US adults - the ACP 2017 guideline recommends non-pharmacologic treatments as first-line, with exercise, multidisciplinary rehabilitation, yoga, motor control exercise, and tai chi all supported. Lin Health's chronic low back pain guide walks through these options condition-specifically.

A 2017 Cochrane exercise overview (Geneen et al.) found small-to-moderate improvements in pain and function across many chronic pain conditions in adults, with the strength of evidence varying by condition. The takeaway is not "exercise solves chronic pain" - it is that consistent, individualized movement is one of the better-evidenced building blocks across chronic pain populations. For condition-specific options, see Lin Health's back pain treatment alternatives.

For chronic non-specific low back pain specifically, a Cochrane review on yoga (Wieland et al., 2017) found small-to-moderate improvements at 3-6 months compared with no exercise.

Practical points:

• A physical therapist can help match the type and dose of movement to the specific condition.
• Graded exposure - slowly rebuilding tolerance for movement that has felt threatening - has evidence in chronic low back pain populations and is part of many rehabilitation programs.
• Movement programs work best when they are sustained, not one-off.

Procedural and Manual Approaches

This category covers therapies delivered by hand or with a device - and the evidence varies considerably by condition.

Acupuncture

The largest individual-patient-data meta-analysis of acupuncture for chronic pain - the 2018 Vickers IPD meta-analysis - found acupuncture significantly more effective than sham and no-acupuncture controls for four conditions: chronic low back pain, neck pain, knee osteoarthritis, and headache. Effects were maintained at 12 months. Outside those four conditions, evidence is weaker.

TENS (transcutaneous electrical nerve stimulation)

A 2019 Cochrane overview (Gibson et al.) found evidence for TENS in chronic pain to be inconclusive due to study quality, with possible short-term benefit in some conditions.

Manual therapy

Spinal manipulation has guideline support for chronic low back pain in the ACP recommendation above. For other chronic pain conditions, evidence is more mixed.

Interventional procedures

Nerve blocks, radiofrequency ablation, and spinal cord stimulation are options for specific, well-selected chronic pain conditions. Patient selection, condition, and clinician experience all matter - these are decisions for a pain specialist, not a self-directed choice.

Mind-Body and Brain-Based Therapies

This category targets the nervous-system processes that keep pain active after tissue has healed. The evidence base here has grown substantially in the last decade.

Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT)

A 2020 Cochrane psychological therapies review (Williams et al.) found small effects of CBT on pain, disability, and mood post-treatment, with effects generally maintained at follow-up. The same review rated evidence for ACT as insufficient to determine benefit, reflecting fewer and smaller trials available at the time. The CBT effects are not large in any individual measure, but they are consistent across studies and populations.

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Mindfulness-based interventions

A 2017 mindfulness for pain meta-analysis (Hilton et al.) found small improvements in pain, depression, and quality of life across chronic pain conditions with mindfulness meditation programs, including MBSR.

Emotional Awareness and Expression Therapy (EAET)

An early randomized trial in older adults with chronic musculoskeletal pain - Yarns 2020 EAET pilot (Pain Medicine) - found EAET produced greater pain reduction than CBT. A larger 2024 randomized clinical trial (Yarns et al., n=126 older veterans with chronic musculoskeletal pain) replicated and extended that finding: EAET was superior to CBT on the primary pain-severity outcome (P<.001), with 63% of EAET participants achieving at least a 30% reduction in pain at posttreatment compared with 17% in the CBT group. The trial population was specific - older veterans with chronic musculoskeletal pain - so the finding is best read as supporting EAET in that population rather than across all chronic pain.

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Pain Reprocessing Therapy (PRT) - for chronic back pain

For a plain-language overview of what PRT involves, Lin Health publishes a PRT introduction for patients. In a 2022 randomized trial - the JAMA Psychiatry PRT trial (Ashar et al.) - Pain Reprocessing Therapy was tested in adults with chronic back pain. At post-treatment, 66% of patients in the PRT group were pain-free or nearly so, compared with 20% in the placebo group and 10% in usual care. Results were largely maintained at one-year follow-up. A 5-year follow-up of the same trial (Ashar et al., 2025, JAMA Psychiatry) reported that 55% of the PRT group remained pain-free or nearly so, compared with 26% in the placebo group and 36% in usual care - supporting durability of the treatment effect. The trial population was adults aged 21-70 with low-to-moderate-intensity chronic back pain of at least six months - so the finding applies specifically to that population. PRT has not been validated in randomized trials for migraine, fibromyalgia, or other chronic pain conditions at the same level of evidence, and should not be assumed to generalize.

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Lifestyle Foundations: Sleep, Stress, Nutrition

Lifestyle factors do not replace condition-specific treatment, but they do meaningfully modulate chronic pain.

• Sleep. Sleep and chronic pain are bidirectionally linked - a 2013 sleep-pain review (Finan et al.) found poor sleep predicts higher next-day pain in adults with chronic pain, and pain disrupts sleep. Sleep regulation is a foundational building block - Lin Health has practical chronic pain sleep tips for readers building this in.
• Stress and emotional state. Affective states modulate central pain processing, per IASP nociplastic pain literature (Kosek et al., 2016). Stress-management practices are not a fix on their own - they reduce one of the inputs that keeps the pain alarm active.
• Nutrition and weight. For weight-loaded joint pain, weight management has evidence in osteoarthritis populations. Anti-inflammatory dietary patterns have weaker evidence for chronic pain broadly - more supportive than primary.

These are foundations, not replacements, for the categories above.

How to Talk With Your Clinician About a Non-Opioid Plan

If you are currently on opioids and considering changes, the most important guidance is from the 2022 CDC opioid guideline itself: opioid therapy should not be stopped abruptly, and any taper should be individualized and clinician-guided. Abrupt discontinuation has its own risks, including withdrawal and increased pain.

A productive conversation with your clinician usually covers:

1. What is the specific diagnosis? Chronic pain is not one condition - chronic low back pain, diabetic peripheral neuropathy, fibromyalgia, and migraine each have different evidence bases.
2. What non-opioid options have actually been tried, at adequate dose and duration? Many medications and therapies are abandoned before they were given a fair trial.
3. What is the goal? Pain reduction, functional restoration, sleep, and mental health are different outcomes - the plan should match the goal.
4. What is the role of a brain-based or behavioral approach? For chronic pain that has not responded to standard medical and rehabilitative care, this is often the missing piece.
5. If tapering, what is the schedule and the safety net? A taper should have a written plan and a clinician available for support.

How Lin Health Helps With Chronic Pain Without Opioids

Lin Health is a clinical-grade digital health program for adults living with chronic pain and other persistent symptoms - not a supplement company, not a content app. The clinical model is based on the science of how pain becomes chronic: after tissue has healed, the brain and nervous system can keep generating pain through learned circuits, sometimes called central sensitization or nociplastic pain. Most opioid-tapering plans address the medication; far fewer address the underlying nervous-system mechanism.

The program is built around that mechanism:

• Coach-led care. Patients work weekly with a trained recovery coach, with chat support between sessions and an app for practice materials.
• Modalities used. CBT, ACT, AET, somatic tracking, and PRT-aligned techniques - protocolized into modules and matched to the patient's condition. Lin Health's clinical approach is based on the body of research summarized above; Lin Health is not the therapy of record in any specific cited trial.
• Insurance covered. Lin Health is in-network with major insurers in high-coverage states (Colorado, Texas, Florida, California, New York, with growing coverage elsewhere). Most enrolled patients pay $0 out of pocket.
• Short wait times. Same-day eligibility check, scheduled physician intake, then a coach match - designed for patients who can't wait months for behavioral care.

For readers who want to see how this looks in practice, Lin Health publishes patient recovery stories and clinical research summaries, and maintains a list of conditions Lin Health treats. The brain-based approach is not for every chronic pain condition or every patient - but for many people who have already worked through the medical and rehabilitative options without lasting relief, it is the category that has not yet been tried.

If you'd like to see whether Lin Health may be a fit for your situation, check Lin Health eligibility.

FAQ

What is the best non-opioid option for chronic pain?

There isn't one best option - the right choice depends on the specific diagnosis. For chronic low back pain, the ACP 2017 guideline supports non-pharmacologic treatments as first-line. For diabetic peripheral neuropathy, gabapentinoids and duloxetine have FDA-approved indications. For chronic pain maintained by central nervous system changes, brain-based therapies have growing evidence. A clinician helps match the option to the diagnosis.

Can chronic pain be treated without any medication at all?

For some people and some conditions, yes - particularly chronic low back pain, where the ACP 2017 guideline supports non-pharmacologic treatment as first-line. For other conditions, including some neuropathic pain syndromes, medication remains an important part of the plan. A medication-free approach is a reasonable goal to discuss with a clinician, but it is not the right plan for every patient.

How do I taper off opioids safely?

Per the 2022 CDC Clinical Practice Guideline, opioid tapering should be individualized, gradual, and clinician-guided. Abrupt discontinuation is not recommended and carries its own risks. A safe taper usually involves a written schedule, regular check-ins, and a plan for managing withdrawal symptoms and underlying pain. Do not change opioid therapy on your own.

Are non-opioid medications safer than opioids for long-term use?

"Safer" depends on the specific medication and condition. Non-opioid medications carry their own risks - NSAIDs have GI, renal, and cardiovascular concerns; tricyclics have anticholinergic and cardiac effects; gabapentinoids can cause sedation. The reason guidelines now favor non-opioid options for most chronic pain is that they avoid the specific risks of long-term opioid therapy - dependence, hyperalgesia, and overdose - while still offering measurable benefit for the right condition.

Do brain-based therapies work for chronic pain that's been there for years?

Yes, for some people. The 2022 JAMA Psychiatry trial of Pain Reprocessing Therapy enrolled adults with chronic back pain of at least six months - average duration was over a decade - and many participants improved substantially. Cochrane evidence for CBT, ACT, and mindfulness-based interventions also includes long-duration chronic pain populations. Long duration is not a disqualifier, though it does change clinical context.

How do I know if Lin Health is right for me?

Lin Health works best for adults with chronic pain or persistent symptoms (chronic pain ≥3 months, including low back pain, neck pain, fibromyalgia, chronic migraine, and others) who are looking for a coach-led, insurance-covered, brain-based program. It is not physical therapy, medication, or surgery. Eligibility takes a few minutes to check, and the patient page outlines the steps.

This article is for informational purposes and is not medical advice. It is not intended to diagnose, treat, cure, or prevent any condition. Do not start, stop, or change any medication - including opioids - without first consulting a qualified healthcare provider.

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