Diversity of Effective Non-Opioid Treatment Options for Chronic Pain
Trigger Point Injection
Myofascial pain syndrome, which affects as much as 85% of the population,  is most commonly related to the presence of trigger points (TPs)  that can potentially develop in any of the body's 400 muscles. Trigger points are situated within the contractile bands of the muscle’s belly, at the proximity of the motor endplate or associated fascia. Active TPs can be painful, whereas latent TPs limit motion range and result in muscle weakness. Trigger points can cause referred pain, described by patients as “dull, aching, deep,” and located in the same dermatome, sclerotome, and myotome as the originating TP. Ultrasound imaging is used to localize TPs to be injected with local anesthetics, sometime in combination with steroids.  Photo credit: Science Source
During neurofeedback, patients are given the opportunity to self-modulate physiological functions. Brain activity associated with pain signals (α and β waves) is monitored using electroencephalogram recordings and conveyed to the patient using visual or auditory cues. The patient is instructed to bring the signal within a desired range of activity. Photo credit: Science Source
Spinal Cord Stimulation
Spinal cord stimulation (SCS) has long been used to manage chronic pain. In particular, stimulation of dorsal root ganglions is effective in relieving focal pain. High-frequency SCS (HF-SCS) at 10 kHz is now preferred over traditional SCS, as this stimulation paradigm allows the achievement of pain relief without paresthesias. Results from several clinical trials have shown efficacy of HF-SCS in alleviating intractable pain in the limbs and trunk.[5,6] Photo credit: Visuals Unlimited
The Neurological Basis of Acupuncture
Acupuncture, which consists of the placement of needles at specific “acupoints” on the skin, has been used for centuries in traditional Chinese medicine. Its effectiveness in pain management has neurological bases: in addition to stimulating the release of endorphins,  it is thought that needle insertion leads to activation of afferent fibers (Aδ and C) ascending through the lateral spinothalamic tract.  Integration of pain signals (in red on the diagram) and acupuncture-mediated signals (in blue) in the central nervous system may result in analgesia. Photo credit: Science Source
Another remedy for pain strongly rooted in traditional Chinese medicine is the use of herbs. Of note, the Corydalis yanhusuo W.T. Wang herb, which contains 2 alkaloids, l-tetrahydropalmatine, and dehydrocorybulbine, both of which have analgesic properties, provides superior analgesic effect for neuropathic pain than each compound separately. [9,10] These properties are at least in part conferred by antagonism of D2 dopamine receptors.
Technology for Pain Management: Actipatch
Technological advances can be harnessed to manage chronic pain. Several noteworthy examples include Actipatch (shown above), an electroceutical device which modulates efferent neural signals that contribute to the maintenance of pain through the process of central sensitization. Electromagnetic stimulation of these pathways at 1 kHz lessens the intensity of pain signals perceived by the brain. Virtual reality, which engages users in a game, thus providing an immersive full-body sensory experience, has also been found to be effective in alleviating chronic neuropathic pain.  Photo credit: BioElectronics Corporation
Abundant evidence indicates the beneficial effects of laughter for the relief of chronic pain. Gelotology – the study of laughter – has led to the identification of a voluntary and involuntary pathway with a common center located in the dorsal upper pons. In addition to these pathways, laughter was found to reduce the breakdown of nitric oxide, thus promoting vasodilation and decreasing stress levels.  It is thought that the beneficial effects of laughter are also mediated through modulation of the muscular, immune, and neuroendocrine systems. In addition, laughter positively affects one’s emotional state, inter-personal skills, and tolerance to pain.
As emphasized in the National Pain Strategy, optimal management of chronic pain requires an integrative approach.  Massage therapy, in addition to exercise and acupuncture were the most recommended by physicians, as indicated in a study for which they were asked to recommend multimodal treatment plans. 
Exercise is known to have beneficial effects on health, acting from the cellular to the behavioral level. In addition, it is thought that exercise leads to hypoalgesia through downregulation of pro-inflammatory cytokines peripherally and downregulation of cytokines and growth factors centrally.  In addition, inactivation of glial cells in the dorsal horn and upregulation of levels of endogenous opioids in the brainstem, and of serotonin, also contribute to exercise-induced hypoalgesia. 
With the rise of the opioid epidemic and the ever-increasing prevalence of chronic pain resulting from conditions ranging from musculoskeletal disorders to neuropathies, efforts geared at developing non-opioid and non-pharmacologic treatment strategies are essential.
Multimodal approaches to the management of chronic pain are favored by pain specialists, as all aspects of the biopsychosocial model need to be addressed for a comprehensive and effective way to address chronic pain.
The treatment approaches presented here, ranging from traditional Chinese medicine to less conventional strategies, have shown effectiveness in treating a wide array of pain modalities, and may be used in combination with more mainstream treatments.
- Gerwin RD. Classification, epidemiology, and natural history of myofascial pain syndrome. Curr Pain Headache Rep. 2001;5(5):412-420.
- Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. J Electromyogr Kinesiol. 2004;14(1):95-107.
- Niraj G, Collett BJ, Bone M. Ultrasound-guided trigger point injection: first description of changes visible on ultrasound scanning in the muscle containing the trigger point. Br J Anaesth. 2011;107(3):474-175.
- Verrills P, Sinclair C, Barnard A. A review of spinal cord stimulation systems for chronic pain. J Pain Res. 2016;9:481-492.
- Kapural L, Yu C, Doust MW, et al. Novel 10-kHz High-frequency Therapy (HF10 Therapy) Is Superior to Traditional Low-frequency Spinal Cord Stimulation for the Treatment of Chronic Back and Leg Pain: The SENZA-RCT Randomized Controlled Trial. Anesthesiology. 2015;123(4):851-860.
- Russo M, Verrills P, Mitchell B, Salmon J, Barnard A, Santarelli D. High Frequency Spinal Cord Stimulation at 10 kHz for the Treatment of Chronic Pain: 6-Month Australian Clinical Experience. Pain Physician. 2016;19(4):267-280.
- Yu JS, Zeng BY, Hsieh CL. Acupuncture stimulation and neuroendocrine regulation. Int Rev Neurobiol. 2013;111:125-140.
- Zhao ZQ. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol. 2008;85(4):355-375.
- Hu JY, Jin GZ. Supraspinal D2 receptor involved in antinociception induced by l-tetrahydropalmatine. Zhongguo Yao Li Xue Bao. 1999; 20(8):715-719.
- Zhang Y, Wang C, Wang L, et al. A novel analgesic isolated from a traditional Chinese medicine. Curr biol. 2014; 24(2):117-123.
- Hoffman HG, Richards TL, Van Oostrom T, Coda B, Jensen MP, Blough DK, Sharar SR. (2007). The analgesic effects of opioids and immersive virtual reality distraction: evidence from subjective and functional brain imaging assessments. Anesthesia and Analgesia, 105(6), 1776-83, table of contents. doi:10.1213/01.ane.0000270205.45146.db.
- Miller M, Fry WF. The effect of mirthful laughter on the human cardiovascular system. Med Hypotheses.2009;73(5):636-639.
- National Pain Strategy. US Department of Health and Human Services. Published March 2016. Available at: https://iprcc.nih.gov/docs/HHSNational_Pain_Strategy.pdf. Accessed September 9, 2016.
- Maiers MJ, Westrom KK, Legendre CG, Bronfort G. Integrative care for the management of low back pain: use of a clinical care pathway. BMC Health Serv Res. 2010;10:298.
- Grace PM, Hutchinson MR, Maier SF, Watkins LR. Pathological pain and the neuroimmune interface. Nat Rev Immunol. 2014;14(4):217-231.
- Gerin CG, Smith K, Hill S, Hill A, Madueke IC. Motor activity affects dopaminergic and noradrenergic systems of the dorsal horn of the rat lumbar spinal cord. Synapse. 2011;65(12):1282-1288.
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