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U.S. Department of Health and Human Services
Opioid Stewardship in the Indian Health Service

Special Considerations

Oral Health

The IHS Division of Oral Health offers approved clinical recommendations [PDF - 767 KB] to reinforce evidence-based acute pain management strategies, including optimizing non-steroidal anti-inflammatory drugs such as acetaminophen, as well as topical/local pain strategies to avoid or reduce opioid exposure.

Learn how dental professionals can identify patients who may be at high-risk for OUD and SUD, while seeking care in the dental setting: Helping Dental Professionals Identify and Support Patients with Substance Use Disorders Exit Disclaimer: You Are Leaving www.ihs.gov  – the American Dental Association (ADA)

Resources for Dental Pain Management

Benefits and Harms Associated with Analgesic Medications Used in the Management of Acute Dental Pain Exit Disclaimer: You Are Leaving www.ihs.gov  – Journal of the American Dental Association (JADA)

Pediatric Patients

Adult Patients

Dental Opioid Stewardship

Please visit The IHS Division of Oral Health for more about Dental Opioid Stewardship, including information, resources, and links to continuing education and toolkits.

Emergency Department

To support frontline clinicians within the ED, IHS has collaborated with the American College of Emergency Physicians who hosts an IHS Toolkit as one of their Pain and Addiction Care in the Emergency Department (PACED)Resources,Exit Disclaimer: You Are Leaving www.ihs.gov  to support Emergency Departments when working to improve pain and addiction care at their local site.

Integrative Care

Many people use health care approaches considered to be outside of mainstream Western or conventional medicine for specific conditions, overall health maintenance, and/or well-being, in addition to conventional treatments. The boundaries between complementary and conventional medicine often overlap and change over time. For example, guided imagery and massage, both once considered complementary or alternative, are used regularly in some hospitals to help with pain management.

Integrative Therapy Treatments include:

  • Movement therapy and exercise: therapists teach various exercises to improve flexibility, strength, core stability, endurance, and range of motion
  • Manual therapy using hands or tools on soft tissue
  • Massage and Deep Tissue Mobilization targeting spasms and chronic muscle tension
  • Manipulation of joints and bones
  • Dry Needling: a technique used to decrease pain and movement impairments through insertion of a thin needle (without medication) or injection into muscle, fascia and connective tissue
  • Pain Science Education: educating patients about the nervous system to improve pain beliefs and physical performance
  • Mind Body Strategies: use of mind-body interventions such as mindfulness training, yoga, guided imagery and Cognitive Functional Therapy (CFT)
  • Modalities of electrical stimulation to nerve and muscle to alleviate pain
  • Ultrasound
  • Cold laser therapy to alleviate inflammation and pain and release endorphins
  • Microcurrent stimulation to alleviate pain

Other approaches include deep breathing, yoga, tai chi, qigong, chiropractic or osteopathic manipulation, meditation, special diets, homeopathy, and progressive relaxation. The NIH's National Center for Complementary and Integrative Health (NCCIH) Exit Disclaimer: You Are Leaving www.ihs.gov  generally uses the term "complementary health approaches" when discussing these practice approaches as well as other non-pharmaceutical products used for various health conditions, such as essential oils, sage, etc.

The Therapist Professional Advisory Committee (TPAC) published a paper that examines the opioid crisis and focuses on how to best care for patients with chronic pain. An abstract is available for free: Physical rehabilitation therapists' perspective of the opioid crisis with evidence-based recommendations (Abstract) Exit Disclaimer: You Are Leaving www.ihs.gov 

IHS Focused Auricular Acupuncture

Results from a number of studies suggest that acupuncture may help ease types of pain that are often chronic such as low-back pain, neck pain, and osteoarthritis/knee pain with minimal safety risk. Studies also suggest that acupuncture may help reduce the frequency of tension headaches and prevent migraine headaches.

The IHS has partnered with the Veterans Health Administration (VHA) to utilize the innovation of the Defense and Veterans Center for Integrative Pain Management (DVCIPM). The DVCIPM auricular acupuncture model is titled ‘Battlefield Acupuncture’ and includes an inter-professional training component as well stepped-care models.

Acupuncture Resources:

Pain Assessment and management standards for hospitals: the Joint Commission

Hospitals must:

  • Actively engage medical staff and hospital leadership in improving pain assessment and management, including strategies to decrease opioid use and minimize risks associated with opioid use
  • Provide at least one non-pharmacological pain modality when clinicians determine need for pain treatment
  • Facilitate access to prescription drug monitoring programs
  • Engage patients in treatment decisions about their pain management
  • Address patient education and engagement, including storage and disposal of opioids to prevent these medications from being stolen or misused by others
  • Facilitate referral of patients addicted to opioids to treatment programs

Learn more from The Joint Commission about key concepts [PDF - 116 KB] Exit Disclaimer: You Are Leaving www.ihs.gov  facilities should understand related to pain management requirements.

References