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Combination Therapy for Noncancer Pain

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Combination Therapy for Noncancer Pain

Combination therapy is becoming a more commonly utilized approach to pain management due to several factors, including (i) the availability of intrathecal drug delivery systems that enable precise dosage control for analgesics and (iii) the rapid advancement of novel drugs with improved efficacy and tolerability. Unfortunately, clinical evidence relating to combination therapy is not as strong as that for single agents. Despite this, there is growing support from research for using spinally delivered medications for treating chronic neuropathic pain [3-5].

Combinations can be highly effective for patients suffering from chronic low back pain (CNCP) and may provide a significant decrease in pain intensity. Furthermore, they may be more cost-effective than single drug treatments or an extensive medical management program. Ultimately, these advantages lead to greater patient satisfaction and better patient outcomes.

In a large study of 202 CNCP patients, who were randomly assigned to either an implantable drug delivery system (IDDS) or comprehensive medical management (CMM), researchers found that the IDDS group achieved greater clinical success (i.e., > 20% reduction in pain scores or other pain-related symptoms at 6 months) than its CMM counterpart did at six months. Furthermore, the IDDS group experienced significantly higher survival rates than its CMM counterpart as well.

Another advantage of IT drug delivery is the availability of a wide variety of opioid and nonopioid analgesics. Compared to oral or parenteral administration, IT analgesics are injected directly into the IT space with significantly lower toxicity levels compared with these therapies. Furthermore, thanks to lower doses, IT therapy could potentially reduce gastrointestinal, respiratory, musculoskeletal adverse effects as well as enhance patient compliance with treatment.

The polyanalgesic consensus panel recommends that patients with IT analgesia be prescribed additional analgesics to achieve a synergistic effect of the drugs taken, and some clinicians have even started this practice themselves. Examples include benzodiazepine receptor agonists, anticonvulsants, neuropeptide ligands and neuropathic opioids.

One of the most commonly prescribed IT analgesics is morphine, which can be administered intravenously via an infusion pump or spinal needles. Morphine has been proven to be an effective analgesic for a wide variety of pain symptoms; moreover, studies have demonstrated that ziconotide – acting as both a neuropathic and opiate receptor agonist – works similarly.

Though the pharmacology of IT analgesia is complex, many agents used to treat it are not FDA-approved. Therefore, physicians should exercise caution when prescribing these medications to patients since their mechanisms of action are unknown. Further research is necessary to better comprehend how IT analgesics function in pain management and whether they can lead to better patient outcomes.

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