Abstract
Back pain refers to pain located in the lumbosacral region, arising without a specific cause. Although most back pain is short-lived, up to 10% of patients progress to a chronic phase.
Back pain is one of the most serious health problems in today's population. Although they are not primarily associated with mortality, they are a widespread cause of disability and deteriorating quality of life.
According to official statistics from developed countries (USA, Canada, EU), 82% of the population suffers from back pain at least once in their lifetime. Chronic back pain not only has a negative effect on the patient, but also has significant socio-economic consequences for his surroundings and for society as a whole.
Chronic back pain should be treated with a multidisciplinary approach, including pharmacotherapy, rehabilitation, psychosocial support, and possibly invasive procedures. Motivation and involvement of the patient is also a prerequisite for successful treatment.
In the pharmacotherapy of chronic back pain we use a whole range of drugs - non-opioid analgesics, anticonvulsants, antidepressants, weak and strong opioids. The use of all these groups of drugs may be justified in individual patients, but we often encounter an approach in which one of these groups is wrongly neglected.
To objectify the intensity of pain, we most often use a visual analog scale (VAS - visual analog rating scale) or NRS (its equivalent in numerical rating scale) with values of 0-10 (resp. 0-100), where the lowest value indicates a state without pain and the highest value condition with maximum imaginable pain. Intensity <= 4 is reported to be tolerable in the long run.
Mutual trust between the patient and the doctor plays a role here; The chronic pain treatment strategy is usually based on the WHO three-level pain ranking. The first stage is a non-opioid analgesic, in the second stage we add a weak opioid and in the third stage the weak opioid is replaced by a strong one.
In indicated cases of very severe pain, the second stage can be "skipped" (VAS 7 and higher) and followed directly by treatment with a non-opioid analgesic with a small dose of a strong opioid. We titrate its dose gradually, individually according to the effect and side effects.
For titration and basic treatment, it is more appropriate to use tablet forms, which allow a faster achievement of a stable plasma concentration and a faster response to possible side effects. In patients who are unable to take drugs in oral form, transdermal dosage forms may be used.
If the effect of the opioid gradually decreases during treatment (tolerance development), we proceed to rotation, ie we replace the opioid used with another with a different active substance. We administer the same or equal to 10-30% lower dose equallyalgesically.