Back Pain

It seems that there is scant good news about opioid pain relievers these days. Maybe for good reason—doctors and patients are besieged with an epidemic of opioid-related overdoses and deaths. And, more often than not, the initial reason for prescribing medications implicated in these deaths was the treatment of pain. Pain experts are reaching a consensus that long-term use of opioid pain relievers is typically not indicated for most pain conditions, requires close monitoring and surveillance, should not be used as “solo” therapy, and almost never justifies higher doses than most guidelines recommend.

Still, like most things in life, you don’t throw out the baby with the bath water. Opioid pain relievers are considered an essential therapeutic by the World Health Organization and remain the mainstay of pharmacological management of many acute and chronic pain conditions. Several studies over the years have demonstrated that opioid medications can have better analgesic effects, and spare patients from exposure to higher doses, when combined with other kinds of pain relievers. There is good reason to believe that using certain medication combinations may be especially effective for managing neuropathic pain conditions.

Neuropathic pain is pain arising from a diseased or damaged nervous system. It can be especially difficult to treat. Neuropathic pain, associated with various conditions including diabetic neuropathy, spinal radiculopathy, postherpetic neuralgia, and posttraumatic neuropathy, exerts a profound adverse impact on affected patients and their families. Population studies of pain with neuropathic characteristics have reported prevalence rates of 7% to 10%. And, neuropathic pain impairs daily activities, mood, quality of life, and work; generates 3-fold higher health care costs, and costs tens of billions of dollars per year in North America alone.

Using an elegant study design, these scientists evaluated a regimen of nortriptyline–morphine, and compared the effects with either drug alone in a group of patients diagnosed with neuropathic pain. For this randomized, double-blind crossover trial, patients with neuropathic pain were enrolled at one site between January 25, 2010, and May 22, 2014, and randomized in a 1:1:1 ratio to receive oral nortriptyline, morphine, and their combination. During each of three 6-week periods, doses were titrated toward a maximal tolerated dose. Patients randomized to receive the combination therapy showed improved pain relief compared to those who received either medication alone. The combination group also reported slightly FEWER common medication side-effects including constipation and dry mouth. The combination group also required slightly lower doses of morphine than the morphine-only group, but this finding did not reach statistical significance.

What does this mean for patients? It means that certain combinations of medication may work better than others for treating neuropathic pain. Finding the right combination for any patient has always been one part art and one part science. Luckily, pain management specialists are getting better at the science part of the equation. The specialists at Columbia Pain Management are experts at managing pain using the best available scientific evidence. Guided by up-to-date studies and new research, we can safely trial combinations of pain relievers that work better together than single pain medications used alone. If you’re feeling stuck, stymied, or frustrated by your lack of improvement in pain and healing, we might be able to help.

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