The pain stack I use instead of opioids — and what the evidence says about each piece

When the CDC released its 2016 opioid prescribing guidance and the wave of state-level restrictions followed, a lot of pain clinics were caught flat-footed. The standard chronic-pain protocol for two decades had been: try NSAIDs, try physical therapy, then write the prescription. When the prescription stopped being available, that left a gap.

I had been working on filling that gap since the early 2000s. Not because I was prescient — because I was at Practical Pain Management as their pain-device expert starting in 2004, watching the device side of the field develop in parallel with the pharmacology side. By the time the opioid restrictions hit, I had a stack.

Twenty-two years and 29 publications later, the stack has narrowed. Here are the four modalities I land on most often, and what the evidence actually supports for each.

1. Pulsed electromagnetic field therapy (PEMF)

PEMF is the modality I've spent the most clinical and editorial time on. My 2023 review with Dr. Erica Tassone in Practical Pain Management pulled together what the research actually shows: in musculoskeletal pain, well-dosed PEMF reduces pain ratings, reduces local inflammation markers, and improves perfusion. The downstream signals — mood, sleep, activity, stress — track the pain reduction.

The mechanism, briefly, is electromagnetic induction at the cellular level. The body's tissues already use electrical signaling. PEMF nudges that signaling, particularly at injured sites where resting electrical activity is disrupted. It is not "energy healing" — it's a measurable biophysical effect with FDA-cleared devices behind it.

When I reach for it: chronic musculoskeletal pain that hasn't responded to two cycles of conventional PT, particularly when there's an inflammatory component. Post-surgical recovery where edema is the rate-limiter.

2. Low-level laser therapy (cold laser, LLLT)

Cold laser was the subject of my first major device review, published in PPM in January 2004. Two decades later, the evidence base has thickened substantially. Photobiomodulation — the formal name now — works by selectively absorbing specific wavelengths of light into mitochondria, which up-regulates ATP production and reduces local oxidative stress.

The clinical translation: faster soft-tissue healing, reduced inflammation, and meaningful pain reduction for tendinopathies, joint pain, and certain neuropathic conditions. The trials that show strong effects use specific wavelength and dosing parameters; the trials that show null effects often used the wrong dose. That's a real problem in the literature, and it's why some clinicians dismiss the modality. With proper dosing, it earns its place.

When I reach for it: tendinopathies (especially shoulder and elbow), localized inflammation, post-surgical scar tissue.

3. TENS — the cheap home device that actually works

Transcutaneous electrical nerve stimulation has been in clinical use for decades, but it's also become a consumer device — $30 units on Amazon, often with mixed-quality waveforms.

My 2019 pilot with Dr. Amy Baxter compared TENS to Vibracool (mechanical vibration) for chronic pain. Both helped. The point of that study wasn't to crown a winner — it was to confirm that non-pharmacologic peripheral nerve modulation works, full stop, and gives patients options.

For chronic-pain patients on a budget, TENS is the modality I recommend most often. It is genuinely useful, it's available at home, and there is now over forty years of evidence behind it. The HealthCentral guide I wrote on TENS units walks patients through what to look for in a unit and how to use it correctly — both matter.

When I reach for it: chronic low back pain, neuropathic pain, fibromyalgia. Anywhere the patient needs a tool they can use between PT visits.

4. Targeted exercise — the non-negotiable foundation

Every other modality on this list is an accelerant. Exercise is the base layer.

My 2016 paper in Practical Pain Management, Health and Economic Benefits of Exercise for Seniors, made the public-health case: resistance training and aerobic conditioning for adults 50+ aren't a lifestyle nicety, they're load-bearing infrastructure for healthspan. The economic argument was striking even then — every dollar spent on senior exercise programming pays back multiples in avoided fractures, avoided hospitalizations, and preserved independence.

That argument has only intensified — see what I wrote on GLP-1 patients last week. But it applies broadly. Almost every chronic-pain patient I see is under-exercising in the specific muscle groups that would offload the pain site. The fix isn't aspirational; it's structured, prescribed, and progressively loaded.

My HealthCentral consumer guide on strength, resistance, and core stability work at home is the version of this most patients can implement without a gym or a trainer.

When I reach for it: every patient. Every visit. No exceptions.

What I told Natural Awakenings in 2022 — and what's changed since

When the magazine quoted me on the opioid-restriction era, I said: "There is no functional restoration in the absence of pain control. Medical devices will play a large and significant role in filling the void that opioid restrictions created."

I believed that then. The four years since have made it institutional. The 2016 CDC guidance I opened with was replaced in late 2022 by a guideline that now states non-opioid therapies are at least as effective as opioids for most common pain — the exact territory this stack treats. The NOPAIN Act took effect in January 2025, so Medicare now pays separately for non-opioid options in surgical settings instead of burying them in a bundle. And that same month, the FDA approved the first new class of non-opioid pain drug in 25 years. The system is catching up to what the device side has known for two decades.

None of that changes the stack. It validates it — three modalities, dosed correctly, layered on top of structured exercise. Slower than a pill, but durable in a way no opioid has ever been.

If you got pulled off an opioid in the past decade and never got an honest replacement plan, the conversation we should be having is which two or three of these modalities are right for your specific picture.