In the use of medicine to treat chronic low back pain physicians are advised to consider the specific needs of the patient when prescribing and scheduling these medications. The goal when prescribing medication to chronic pain patients should be to derive maximum benefits or reduction of pain and discomfort, encourage compliance and minimize the risk of overuse or abuse of the medications.
Non-Steroidal Anti-Inflammatory Medications (NSAIDs)
This group of drugs includes common over-the-counter drugs such as aspirin, ibuprofen, and ketoprofen among others.
These drugs have potent analgesic effects that can be sustained for long periods of time without concerns of toxicity or dependence. These drugs have almost specific effects in reducing pain and inflammation of inflammatory spondyloarthropathies. By the anti-inflammatory and analgesic activity of these medications, they can promote the initiation and maintenance of rehabilitation efforts that might otherwise be impossible.
Opioid therapy or narcotic administration for the purpose of controlling chronic back pain is widely rejected because of potential toxicity to the body, physical dependence, and the loss of efficacy due to developmental tolerance and psychological dependence or addiction.
There is a select group of patients with chronic nonmalignant pain, including low back pain that can experience sustained improvement in comfort from opioid drugs without developing toxicity to the body or having any evidence of psychological dependence or addiction. Treatment by this class of drugs should in essence be the last resort, when patients do not at all respond to all reasonable non-opioid drugs. In addition, patients must be warned about the side effects of this class of drugs and it is strongly encouraged that patients being treated with opioid drugs be forced to have an ongoing conversation with their doctor. There should be an agreed upon period of consistent increase in dosage of the drug (titration) until the patient sees a minimum partial relief of pain. Monthly visits should be required from that point.
Pain has been characterized as a multidimensional phenomenon involving many different systems in the body. As of yet, there is little known about the basic mechanisms that produce or perpetuate the sensory component of pain after tissue damage. There is also little known about the individual person's behavioral response to pain. This is particularly true for chronic pain.
Four basic issues should be addressed to ensure the appropriate use of psychiatric mediations for low back pain. First, the healthcare provider should have a clear understanding of the etiology of the patient's pain in order to decide whether the pain will be responsive to the drugs. In addition, psychiatric disorders causing the pain or disability should be diagnosed accurately so that the appropriate target symptoms can be identified for treatment. Secondly, patients must be detoxified from analgesics or sedative-hypnotic medications in order to evaluate perceived pain and functional capacity and to predict treatment outcome.
Patients must keep in mind that psychiatric medications are an additional element and not a substitute for a comprehensive treatment plan for chronic pain. The comprehensive treatment plan should involve the healthcare provider and the patient and should include education, physical reconditioning, behavioral assessment and evaluation of family and occupational roles. Lastly, constant and attentive follow-up is necessary to chart progress, to detect recurring symptoms or to discontinue ineffective treatment.
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