1. Medications for Spine Pain
Jerome Schofferman, MD
Chair Committee on Ethics and Professionalism
Founder and Member: Rehabilitation, Intervention and Medical Spine Section
North American Spine Society

2. Disclosures
Board of Directors: NASS
Financial: Nothing to Disclose

3. Characterizations of Pain
Duration of Pain
Acute
Less than 3 months
Subacute
3-6 months
Chronic
Severity
Mild
Moderate
Severe
Cause
Structural
Disc
Spinal narrowing
Nerve damage
Idiopathic
Don’t know cause
Unknown
(Other)

4. Approach to Pain is Interdisciplinary
Rehabilitation
Exercise
Physical Therapy
Interventions
Spinal Injections
Medications
Psychology
Surgery
However, it is rare for medications to be the sole treatment or solution to spine pain

5. “At last, an exercise pill that really works”

6. Medications for Spine Pain
Acetaminophen
Tylenol ®
NSAIDs
ibuprofen
naproxen
Muscle Relaxants
Flexeril ®
Soma ®
Opioids
morphine
Oxycontin ®
fentanyl
Antidepressants
duloxetine
Anticonvulsants
gabapentin
Others

7. Goals Primary Goal While
Match Appropriate Medication to the Characteristics and Duration of the Pain
Reduction of pain
Improvement of Function
While
Minimizing Adverse Effects
Especially addiction and death re: opiods

8. Effectiveness
Function
Side Effects
Pain Control
Balance

9. Matching Pain Medication with Pain
Acute Pain
Mild
Acetaminophen
NSAID
Muscle Relaxant
Moderate
Apap or NSAID
? Muscle Relaxant
? Add weak opioid: Goal is to keep patient fnxl
Most patients have already tried
Evidence of efficacy weak
Effect size is small (don’t help all that much)

10. Matching Medication with Pain
Acute Pain
Severe
Corticosteroid ?
Weak or moderate strength opioid
Short-acting
7-10 day supply only w. f/u then
Published Evidence is Weak
Goal is FUNCTION

11. Chronic Pain Mild to Moderate Structural Sequential (?) trials
Antidepressants
Anticonvulsants
Weak to moderate Opioid
Only after failure of other treatments
Therapy trial for effectiveness

12. Chronic Pain Severe Pain Structural Antidepressants Anticonvulsants
Stronger Opioids
Only Occasionally Effective

13. Chronic Pain Structural Nerve Damage Mixed (Both) Neither “Neurogenic”
OPIOIDS
ANTIDEPRESSANTS
ANTICONVULSANTS

14. Opioids for Chronic Spine Pain
There is a small role for opioid analgesics
Carefully selected patients
Refractory pain and disability
Administered carefully (pain specialist?)
Regular follow-up
Demonstrated effectiveness
Urine testing
For “dirty urine”
Regular checks with PDMP

15. Long-term opioid analgesic therapy
“Nothing either good or bad,
but thinking makes it so”
Shakespeare, W
Hamlet 1606; Act 2, scene 2

16. Opioid Analgesics
There are Risks

17. Opioid Analgesics: There are Risks:
to the Public Health
Increased mortality
Diversion
For profit
For recreational use especially by others (abuse)
Increased health care utilization (ER visits)

18. Morbidity and Mortality Weekly Report January 1, 2016

19. ?
Successful Pain Control
Year

20. Opioid Analgesics: There are Risks:
to the Public Health
Increased mortality
Diversion
For profit
For recreational use especially by others (abuse)
Increased health care utilization (ER visits)

21. Opioid Analgesics: There are Risks:
to the Public Health
to the Individual
Side effects
Most readily manageable
Dependence
Addiction
Psychological deterioration
Death

22. Chronic Intractable Pain
There Are Risks As Well

23. Untreated Intractable Pain
To the Public Good
Increased health care utilization
Loss of productivity
To the Individual
Decreased function
Activities of daily living
Work
Family interactions
Insomnia
Fatigue
Alcoholism

24. Untreated Intractable Pain
Psychological disorders due to pain
Depression
Fear Avoidance (fear of doing things that might increase the pain)
Anxiety disorders
Cognitive deficits (difficulty with thinking clearly)
Suicide

25. When All Else Fails “It may surprise you to hear that, actually,
morphine is the best medicine”

26. Medications for Spine Pain
There is a role for medications for patients with spine pain
Important to match the patient’s disorder with the right medication for that PATIENT
Medications can play a useful role but must be accompanies by rehabilitation and when indicated spinal injections and even surgery

27. Thank You