Pain management without opioids: options to discuss with your clinician

What are non-opioid options for pain?

Non-opioid options are ways to manage pain without an opioid medicine. They include movement, therapy, mind and body practices, and devices. The CDC and NIH both describe such options. Your clinician helps you choose among them.

The CDC Clinical Practice Guideline for Prescribing Opioids for Pain, 2022, is written for clinicians. It says: “Nonopioid therapies are preferred for subacute and chronic pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks to the patient.”

The National Center for Complementary and Integrative Health (NCCIH) is part of the NIH. It says: “A growing body of evidence suggests that some complementary approaches, such as acupuncture, hypnosis, massage, mindfulness meditation, music-based interventions, spinal manipulation, tai chi, qigong, and yoga, may help to manage some painful conditions.”

Words such as “may help” matter. These sources do not promise that any option works for every person or every type of pain. Learn more about this topic in our glossary entry on non-opioid pain management.

Should I change my medicine because of this page?

No. This page is not medical advice. Do not start, stop or change any medicine on your own, and do not cut a dose because of something you read here. Talk with the clinician who prescribes it.

The CDC guideline itself warns against sudden changes. It says: “Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages (recommendation category: B; evidence type: 4).”

That sentence is addressed to clinicians. It shows why any change to a medicine must be a shared decision with your prescriber. Your plan may also include medicines that are not opioids. Your prescriber and your pharmacist can explain each one, its purpose and its risks. If you want to talk about your pain plan, you can ask, “What other options could we add?” That is a safe question to bring to a visit.

Where does a TENS unit fit?

A TENS unit is one non-drug option. It sends mild electrical pulses through pads on the skin to relieve pain. The federal rule, 21 CFR 882.5890, says it is used “to treat pain.” Read our guide to TENS units for the basics.

A 2022 review in the journal Medicina found that “TENS may have efficacy for a variety of acute and chronic pain conditions, although the magnitude of the effect remains uncertain due to the low quality of existing literature.” The NHS adds: “TENS does not work for everyone.”

A TENS unit is a tool that a clinician may add to a larger plan. It is not a replacement for medical advice or for a prescribed medicine.

How does a TENS unit relieve pain?

The NHS says TENS is “thought to work by encouraging your body to release natural painkillers called endorphins and by stopping pain messages from your nerves reaching your brain.” Two glossary terms explain the ideas: endorphins and the gate control theory of pain.

What do exercise and physical therapy add?

Movement and guided therapy are common parts of a pain plan, and a physical therapist can tailor them to you.

The University of Iowa Health Care page says that “Research has shown that TENS is most helpful for chronic pain when used for at least 30 minutes while you are active.” It also says TENS helps most during activities such as walking, doing chores, or exercise. So movement and a TENS unit can go together, if your clinician agrees.

For back pain, our blog has practical reading, such as exercises for lower back pain and how to prevent back pain in old age. For general movement, see the benefits of mobility exercises and 5 benefits of walking. Those posts are general reading. They do not replace a plan from your physical therapist.

What about heat, cold and electrotherapy?

Heat, cold and electrotherapy are other options to ask about. Electrotherapy is a broad term for electrical current used in care. TENS is one kind. Others, such as NMES and interferential therapy, differ in their goal. Our guide to TENS vs EMS, NMES and interferential explains the differences.

Our post on cryotherapy and electrotherapy covers this topic in general terms. Ask your clinician before you use heat, cold or electrical devices on an area of pain, especially if you have numb skin, a skin problem or an implanted device.

Who is a good candidate for a trial of TENS?

Your clinician decides, after an exam. The Medicare TENS policy (LCD L33802), as of the revision effective January 1, 2024, gives a picture of how one payer frames it. It covers TENS “for the treatment of beneficiaries with chronic, intractable pain or acute post-operative pain when one of the following coverage criteria, I or II, are met.”

For chronic pain, it says “The pain must have been present for at least three months.” It also says “Other appropriate treatment modalities must have been tried and failed.” The policy lists headache as a condition for which TENS is not considered reasonable and necessary. It also says, “TENS therapy for Chronic Low Back Pain (CLBP) will be denied as not reasonable and necessary.”

Other plans have their own rules, so check with your plan. Our insurance coverage guide and how to get a TENS unit explain the process.

What are the limits of TENS?

TENS has limits, and a good pain plan accounts for them. The evidence is mixed in quality, the effect size is uncertain, and it does not work for everyone. It also has safety limits.

The NHS says, “Do not use TENS if: you have epilepsy; you have a pacemaker; you’re pregnant, unless your doctor or midwife tells you to.” The University of Iowa Health Care page says, “Do not use TENS if you have: A cardiac pacemaker or defibrillator.” It also lists “Any part of your head or face” and “Any part of your throat” as places where you should not use TENS. Read the full list in our TENS unit safety guide. For related terms, see chronic pain and contraindication.

Always follow your clinician’s instructions and your device’s instructions. If you notice skin irritation, headache, dizziness or nausea, the University of Iowa page says to stop using TENS and talk with your doctor or health care team.

What does NIH say about back pain and arthritis?

Back pain and arthritis are common reasons people look for non-opioid options. NCCIH reports that “Not all people with chronic pain have a health problem diagnosed by a health care provider, but among those who do, the most frequent conditions are low-back pain or osteoarthritis, according to a national survey.”

For chronic low-back pain, a separate NCCIH page for clinicians says: “There’s low- or moderate-quality evidence that a variety of mind and body practices, including acupuncture, electromyography biofeedback, low-level laser therapy, mindfulness-based stress reduction, progressive muscle relaxation, spinal manipulation, tai chi, and yoga, may be helpful for chronic low-back pain.” Note the words “low- or moderate-quality evidence” and “may be helpful.” They set honest limits.

TENS for chronic low back pain is a special case under Medicare. The policy says it “will be denied as not reasonable and necessary.” That is a coverage rule, and it does not say what is right for you. Read more in our chronic low back pain entry and on our back pain page. A related post explains the Medicare rule for chronic low back pain.

How do I know whether my plan is working?

A pain plan works when it helps you do more of what matters to you, safely. You and your clinician can judge this with a simple record. Pain scores help, but so do daily tasks.

Bring the record to each visit, and bring your questions too. If a step does not help, say so. Your clinician can adjust the plan. The University of Iowa page gives one example for a TENS unit. If you get no pain relief, it suggests to “Try a different setting” and to “Call your health care team for help if you cannot get relief.” Follow your clinician’s and your device’s instructions for any setting.

Which clinicians can help build the plan?

Several kinds of clinician can help. Start with the one who knows you well, then ask for a referral if you need more support. A primary care doctor can review your history and your medicines. A physical therapist can design movement and may monitor a trial of a device.

Some people also see a pain specialist, a mental health professional or a pharmacist. A plan with a team and a clear goal is easier to follow. If you are a clinic and want to refer a patient for a TENS unit, see our guide for providers.

What if I have more than one health problem?

Tell every clinician about every condition and every medicine, including those you buy without a prescription. Some conditions change which options are safe. For example, the University of Iowa page says to talk with your health care provider if you have cancer, diabetes, cognitive impairment, epilepsy, or are pregnant. Bring that list to the visit.

What should I remember?

Remember three things. First, the CDC prefers nonopioid therapies for subacute and chronic pain, and it asks clinicians to avoid sudden changes to opioid therapy. Second, the NIH says some approaches “may help,” not that they always do. Third, a TENS unit is one tool, with real limits, and your clinician should guide its use.

Keep this page as a starting point for a talk with your care team. It does not replace that talk.

What should I ask my doctor about my pain plan?

Bring a short list of questions to your visit. Write the answers down. A good plan states the goal, the steps, and the date of the next check.

1. What is causing my pain, as far as we know?
2. What non-drug options fit my pain and my health?
3. Could a physical therapist help me with a plan?
4. Is a TENS unit a good option to try, and for how long?
5. What should I track at home?
6. What are the warning signs that I should call you?
7. How do my current medicines fit with these options?

Our guide to getting a TENS unit explains the written order and trial steps. Keep your own notes in one place. They make each visit more useful.

Next step

Talk with your doctor or physical therapist about the options above, and do not change any medicine on your own. If you have questions about TENS units, call Analgesic Healthcare at (800) 749-1188 or use Contact.

This page gives general information, not medical advice. Talk with your doctor or physical therapist about your own care, and follow your clinician's and your device's instructions. In an emergency, call 911.