Non-Opioid Pain Management in Patients With Substance Use History and Gabapentin Intolerance
Nonopioid strategies are recommended for subacute and chronic pain, including acetaminophen, NSAIDs, selected antidepressants, and selected anticonvulsants, with an overall focus on minimizing opioid exposure. [1] Gabapentin should be avoided in the setting of clinically significant adverse effects such as dizziness. [1]
Medication Selection Algorithm
- Thiazide-type diuretics are not relevant to analgesic selection in this context.
- NSAIDs (including topical NSAIDs such as topical diclofenac and systemic NSAIDs) are recommended nonopioid pharmacologic options for multiple chronic pain conditions. [1]
- SNRI antidepressants (including duloxetine) are recommended nonopioid pharmacologic options for chronic pain conditions. [1]
- Tricyclic antidepressants (including amitriptyline) are recommended options for neuropathic pain when clinically appropriate. [2]
- Topical local anesthetics for localized neuropathic pain (including capsaicin cream for localized neuropathic pain that should be used when oral options are avoided or not tolerated). [2]
- Anticonvulsant-class agents for neuropathic pain (including pregabalin) are recommended options in neuropathic pain, but pregabalin can also cause dizziness and sedation. [2]
Key Evidence Supporting This Recommendation
Nonopioid pharmacologic therapies are supported in chronic pain conditions, including evidence that NSAIDs and duloxetine provide small-to-moderate improvements in pain and function for some indications and that acetaminophen has limited effectiveness for osteoarthritis. [1] Nonopioid pharmacologic therapies are associated with adverse effects that guide selection, including dizziness with pregabalin and adverse effects such as sedation and cognitive effects with gabapentin and pregabalin. [1]
Monotherapy Versus Combination Therapy
Topical NSAIDs are recommended for osteoarthritis when a single or a few superficial joints are affected. [1] Systemic NSAIDs or duloxetine can be used when topical NSAIDs are insufficient or when osteoarthritis pain involves multiple joints. [1] Neuropathic pain pharmacotherapy can be adjusted by switching between recommended first-line options when the initial drug is not effective or not tolerated. [2]
Important Clarifications and Nuances
Increased adverse effects from central nervous system depressant co-treatment is addressed in opioid prescribing guidance, including caution with sedating anticonvulsants such as gabapentin and pregabalin. [1] For neuropathic pain in non-specialist settings, recommended initiation and switching should include early follow-up focused on tolerability and adverse effects. [2]
Initiation Thresholds or Indications
For subacute and chronic pain, a nonopioid-first approach is recommended, with opioid therapy reserved for situations where benefits outweigh risks after nonopioid options are used. [1] For neuropathic pain (except trigeminal neuralgia), an initial trial among amitriptyline, duloxetine, gabapentin, and pregabalin is recommended, with switching if not effective or not tolerated. [2]
Common Pitfalls to Avoid
Gabapentin should not be continued when clinically significant dizziness occurs, since gabapentin and pregabalin are associated with adverse effects that can impair cognition and cause sedation-related harms. [1] Acetaminophen should not be used as a first-line treatment for osteoarthritis because effectiveness is limited. [1] NSAIDs should be used with attention to major risks, including serious gastrointestinal events and major coronary events. [1]
Target Pain-Control Goals
Treatment selection should be monitored using clinical review of pain control, impact on daily activities and sleep, adverse effects, and continued need for treatment. [2] Nonopioid care should aim to improve pain and function while limiting medication-related harms in the setting of substance use disorder risk. [1]