Evidence summary for non-opioid pain mgmt

Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review –  a thorough 23-page PDF document from AHRQ (Agency for Healthcare Research and Quality)

Scope and Key Questions

This Comparative Effectiveness Review focused on noninvasive nonpharmacological therapy, with a Key Question (KQ) for each of five common chronic pain conditions:

  • KQ 1: Chronic low back pain
  • KQ 2: Chronic neck pain
  • KQ 3: Osteoarthritis (knee, hip, hand)
  • KQ 4: Fibromyalgia
  • KQ 5: Chronic tension headache

Sadly, there’s no mention of pain caused by genetic disorders, like EDS or sickle cell.  

The strength of evidence was low (limited confidence in the estimates) or insufficient (no confidence in the estimated effects) for many interventions and was limited by small numbers of trials for specific comparisons at our specified time frames, particularly for long-term followup.

In general, effect sizes for most interventions were small, based on mean diffe.rences

No trials directly compared interventions with opioids and few trials reported effects of interventions on opioid use.

Harms were poorly reported across interventions.

These would be harms like the joint damage caused by forcing “typical” PT exercises upon EDS patients with their loose tendons and ligaments from defective connective tissue.


The applicability of our findings may be impacted by a number of factors.

Included trials provided limited information on,

  • symptom duration,
  • clinical characteristics,
  • comorbid conditions and
  • concomitant treatments,

thus it is not clear to what extent this reflects the populations seen in clinical practice or how these factors impact our results.

Yet, this is the exact information used by doctors to make a differential diagnosis.

It sounds like these non-pharmaceutical therapies are used indiscriminately for any condition the patients have.

information regarding diagnostic criteria for the pain condition of interest was limited.

There was also heterogeneity in populations enrolled in the trials with regard to duration of chronic pain, severity of pain (most trials enrolled patients with at least moderate pain at baseline), as well as other factors (e.g., use of medications, medical and psychological comorbidities).

Implications for Clinical and Policy Decisionmaking

Our review also has policy implications related to treatment access and reimbursement.

Given heterogeneity in chronic pain, variability in patient preferences for treatments, and differential responses to specific therapies in patients with a given chronic pain condition, policies that broaden access to a broader array of effective non-pharmacological treatments may have greater impact than those that focus on one or a few therapies.

Because the level of supporting evidence varies from condition to condition, policymakers may need to consider the degree to which evidence may be reasonably extrapolated across conditions (e.g., effectiveness of psychological therapies for chronic back pain may not necessarily be extrapolated to osteoarthritis)

Finally, they point out what pain patients know only too well: these therapies (like exercise) cannot be extrapolated to ALL chronic pain conditions.

Research Recommendations

The gaps in the available evidence are many across the common conditions we included (Table N).

Four primary issues relate to the need

  • (1) to understand the longer-term sustainability of intervention effects;
  • (2) for standardization of interventions for future trials;
  • (3) for standardization of research protocols for collection and reporting of outcomes including harms; and
  • (4) for comparisons of interventions with pharmacological interventions

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