Opioid and Non-opioid Therapy

Despite many advances made in the field of interventional pain management in the past decades, pharmacological therapy often remains the core of the spine pain multimodal treatment. It represents an indispensable therapeutic tool, especially when more interventional methods either failed or are not indicated. This chapter is devoted to describing both neurobiological basis and clinical utility of pharmacological agents used to treat chronic spinal pain. Opioid analgesics have been the mainstay for treatment of pain for centuries. Although opioids may be very useful in treating severe pain conditions, the gravity of their side effects and recently recognized “opioid epidemic” lead to imposing much stricter control of their utilization. NSAIDs (nonsteroidal anti-inflammatory drugs) probably remain the most widely used class of drugs to treat chronic spinal pain because of their ability to reduce pain and inflammation. Centrally acting muscle relaxants are a diverse group of medications with different mechanisms of actions that may be used as an adjuvant treatment, especially when spinal pain is associated with painful muscle spasms. Some antidepressants [tricyclic antidepressants (TCAs) and selective norepinephrine reuptake inhibitors (SNRIs)] have demonstrated their efficacy in treatment of spinal neuropathic pain. Select anticonvulsants, such as gabapentinoids, are also widely used to treat such pain. Topical medications of different classes may have an advantage of exhibiting analgesia without significant systemic absorption. Although there is still insufficient evidence to recommend cannabinoids for spine pain treatment, we discuss this emerging medication class because it has been already used to treat certain pain conditions.