Need for CHANGE: Mechanism orientated therapy
The management of acute back pain and chronic back pain differs, yet the physician should always consider the risks for acute pain becoming chronic and persistent. Acute pain management focuses on physical therapy, stimulating the patient to move as soon as possible, use of pharmacological analgesia and stimulation to relieve pain. By contrast, the management of chronic back pain is often more complex and involved. Reduction in chronic back pain is best achieved through a program involving multimodal management, in which physical and sport therapy, psychological support and management, stimulation therapy, and pharmacotherapy are used in combination according to the patient’s pain diagnosis and individual needs. It is rare that a single management or therapeutic approach can address the problem of chronic back pain.
Appropriate management has the potential to reduce the number of people living with disabling long-term back pain. A key focus should be on helping patients with persistent, non-specific back pain self-manage their condition. The aim of treatments is to reduce pain and its impact even if the pain cannot be cured completely.1-6
Chronic pain often involves more than one mechanism. It is seldom controlled by a single pharmacological principle.
A combination of drugs, or use of agents combining more than one analgesic mechanism of action, targets multiple pain pathways and offers the potential of synergy of effect.7 Certain agents that are associated with risk of severe side-effects, for example, NSAIDs and COX inhibitors, and a patient’s individual risk, for example, treatment-related gastrointestinal bleeding or cardiovascular adverse effects, should be considered.6, 8 When drugs have complementary pharmacokinetic profiles, they can be used together, possibly offering a reduced side-effect profile as compared with higher-dose single agent treatment.
Methods of combining drugs include use of single, loose-drug combinations and fixed combination preparations (formulated to contain two agents). The use of free combinations may be limited by the difficulty of maintaining the dose-ratio within the desired therapeutic range and the possibility of poor adherence. This limitations could be overcome by using fixed-dose combinations or analgesics with more than one mechanism of action.7
New analgesics with more than one mechanism of action in a single molecule offer the advantage of addressing different underlying mechanisms.7, 9
1 Chou R et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147:478-91. 2 Forde G Adjuvant analgesics for the treatment of neuropathic pain: evaluating efficacy and safety profiles. J Fam Pract. 2007; 56(2 Suppl Pain):3-12.
3 Grabois M. Am J Phys Med Rehabil. 2005;84:S29-41.
4 Hayden JA, et al. Cochrane Database Syst Rev. 2005;3:CD000335.
5 Savigny P, et al. BMJ. 2009;338:b1805.
6 National Institute for Health and Clinical Excellence (NICE). NICE clinical guideline 88.Low back pain: Early management of persistent non-specific low back pain. 2009. Available at: http://www.nice.org.uk/nicemedia/live/11887/44343/44343.pdf.
7 Morlion B. Pharmacotherapy of low back pain: targeting nociceptive and neuropathic pain components. Curr Med Res Opin. 2011; 27:11-33.
8 Roelofs PD, et al. Cochrane Database Syst Rev. 2008;1:CD000396.
9 Varrassi G et al. Pharmacological treatment of chronic pain – the need for CHANGE. Curr Med Res Opin. 2010; 26(5):1231-1245.