OBJECTIVES:  Escalating rates of prescription opioid use and abuse have occurred in the context of efforts to improve the identification and management of non-malignant pain. To characterize the diagnosis and management of non-malignant pain in ambulatory, office-based settings between 2000 and 2010. METHODS: Serial cross-sectional and multivariate regression analyses of the National Ambulatory Medical Care Survey (NAMCS), a nationally representative audit of office-based physician visits. The main outcome measures were 1) Annual volume of visits among adults with a primary symptom or diagnosis of pain, and 2) prescription opioid and non-opioid pharmacologic therapy in visits limited to new musculoskeletal pain. RESULTS: Primary symptoms or diagnoses of pain consistently represented one-fifth of visits, varying less than 2% from 2000 through 2010.  Patient-reported pain comprised 17% to 19% of visits, whereas provider diagnoses of pain increased nearly 50% from 2000 (5.7% of visits with pain as a primary diagnosis) to 2010 (8.5%).  Among all pain visits, opioid use nearly doubled from 11.3% to 19.6%, whereas use of non-opioid analgesics remained unchanged (26%-29% of visits).  Pain medications were associated with one-half of new musculoskeletal pain visits, with the use of non-opioid pharmacotherapies decreasing from 38% of visits (2000) to 29% of visits (2010).  After adjusting for potentially confounding covariates, few patient, physician or practice characteristics were associated with the use of non-opioid rather than opioid analgesia. CONCLUSIONS: Increased opioid use during the past decade has not been accompanied by similar increases in non-opioid analgesics.  Clinical alternatives to prescription opioids may be underutilized as a means of treating ambulatory non-malignant pain.