Opioid Stewardship and Gastrointestinal (GI)-Sparing Alternatives in Primary Care Pain Management

Chronic pain is a widespread condition that affects nearly 30% of adults worldwide and is a leading cause of disability. In the United States, primary care providers (PCPs) play a central role in managing chronic pain. While opioids were historically a common solution, their overuse has contributed to a national crisis involving addiction and misuse. In primary care, managing chronic pain requires balancing effective treatment with minimizing associated risks. Opioid stewardship has emerged as a critical strategy to ensure safe prescribing, while growing awareness of nonsteroidal anti-inflammatory drug (NSAID)-associated gastrointestinal (GI) toxicity underscores the need for GI-sparing alternatives. This narrative review aims to provide PCPs with a comprehensive overview of opioid stewardship principles and evidence-based, GI-sparing alternatives for chronic pain management in outpatient settings. Following SANRA (Scale for the Assessment of Narrative Review Articles) guidelines, a comprehensive literature search was conducted using PubMed, MEDLINE, EMBASE, and the Cochrane Library for English-language publications from 2010 to 2025. Relevant guidelines, reviews, and clinical studies were organized thematically to reflect best practices in opioid risk mitigation, GI risk management, and alternative pain therapies. Key components of opioid stewardship in primary care include patient risk assessment, informed consent, conservative opioid initiation, regular monitoring, and deprescribing when appropriate. GI risk mitigation strategies involve careful NSAID use, co-prescription of proton pump inhibitors (PPIs), and consideration of cyclooxygenase-2 (COX-2) selective agents. Evidence-based, GI-sparing alternatives include acetaminophen, antidepressants, anticonvulsants, topical agents, and non-pharmacological approaches such as physical therapy, cognitive behavioral therapy, and mind-body interventions. The implementation of safe and effective chronic pain management in primary care faces several challenges, including time constraints, limited access to non-opioid or GI-sparing therapies, insurance coverage gaps, and patient resistance to change. This review emphasizes practical strategies such as provider education, interdisciplinary teamwork, and electronic health record (EHR) integration to overcome these barriers. A balanced, patient-centered approach is essential to minimize harm from opioids and GI toxic medications while ensuring long-term, sustainable pain relief.