Non-Pharmacologic and Integrative Therapies
How they work
Non-pharmacologic strategies act through several mechanisms: gate control (TENS, massage, vibration, cold), descending modulation (relaxation, slow breathing, distraction, guided imagery, hypnosis, mindfulness), cortical reappraisal (cognitive behavioral therapy, pain neuroscience education), and peripheral modulation (heat, cold, positioning, splinting, acupuncture). Environmental and comfort measures - clustering care, reducing noise and light, music, aromatherapy, pet and spiritual care - are legitimate components of a plan.
Safety and contraindications
Cold should not be applied over areas with poor circulation, Raynaud phenomenon, or numb skin. Heat is avoided over acute inflammation, active bleeding, and the pregnant abdomen. TENS electrodes are not placed over the carotid sinus, anterior neck, eyes, broken skin, a pregnant uterus, or the chest of a patient with a pacemaker. Massage requires caution with anticoagulation or suspected deep vein thrombosis.
Assessment and personalization
Ask what the patient has used, what worked, and what fits their culture, beliefs, and body. Offer choices rather than a single mandatory technique, and document the modality, duration, and response just as you would a medication. These therapies are adjuncts: they reduce distress and opioid requirements but rarely eliminate severe acute pain alone.
Traps
Never imply that using a non-drug technique means the pain is "in your head" - that damages trust and adherence. Distraction is effective for mild to moderate pain and procedure-related distress, not as a substitute for analgesia in severe pain. Do not assume every patient wants to be touched, and do not apply a technique the patient declines. Avoid claiming evidence that does not exist; describe benefits honestly as comfort and coping.
Rule of thumb: pair one pharmacologic and one non-pharmacologic strategy, document both, and reassess; the patient's preference decides which technique is used.