**3. World Health Organization's stepwise approach to pain**

Prior to initiating any pharmacologic treatment regimen for a patient, current consensus recommendations include discussing realistic expectations with the patient [1]. This should include patient's expectations of pain relief as well as functional goals that the patient should work toward. Additionally, the clinician should encourage self‐care and education with evi‐ dence‐based materials. It is important to emphasize to the patient that acute low back pain has very favorable improvement in the first month of recovery. Generally speaking, staying active and exercising should be highly encouraged for all patients. Bed rest should only be recom‐ mended if it improves severe pain symptoms and its duration should only be temporary.

There are several important concepts that a clinician must understand before they can ade‐ quately start the treatment of low back pain. The first is that there is more data on the use of medication for acute low back pain than chronic low back pain [1]. This does not mean that specific pharmacologic agents are not effective in the setting of chronic low back pain, but simply that there is less evidence due to constraints in studying the long‐term side effects [1]. When initiating the therapy, the clinician should focus on medications with the most known efficacy for the specific cause of pain and that have the least risk for serious side effects [1]. Specifically, the drug class and sometimes the even the individual drug chosen will be dic‐

Treatment should include a targeted approach to the individual's cause of low back pain. The majority of low back pain is caused by a mechanical etiology [2]. These causes include degen‐ erative disk or joint disease, vertebral fracture, and deformities and occur in up to 80–90% of patients. Neurogenic (e.g., herniated disks, spinal stenosis) inflammatory (e.g., rheuma‐ toid arthritis, ankylosing spondylitis) and other less common causes (e.g., neoplasm, referred pain) make up the remainder of etiologies. The pharmacologic agents first selected should be completely dependent on the underlying etiology. However, as the pain progresses to a chronic state, a broader approach typically must be taken due to decreased efficacy of the

The majority of this chapter will focus on the treatment of low back pain with an underlying mechanical etiology since it is by far the most common. However, if the cause of low back pain is inflammatory in nature, targeted therapy should also focus on treatment with anti‐ inflammatory agents. This may mean early use of nonsteroidal anti‐inflammatories (NSAIDs) and treatment with corticosteroids or disease‐modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis or ankylosing spondylitis [3]. Additionally, these disease states have a higher incidence of neuropathic pain and thus may require adjuvant medica‐ tions that target this specific pain type. Some patients with mechanical low back pain also have increased pain due to spasticity and may benefit from treatment with antispasmodics. These agents will be discussed in much greater detail later, but to put it simply treatment

Patients should also be encouraged to resume activity as quickly as possible.

tated by side effects (short and long term) and targeted mechanism of pain.

**2. Multimodal and targeted treatment approaches**

184 Pain Relief - From Analgesics to Alternative Therapies

targeted treatment.

should be tailored to the individual.

In 1986, the World Health Organization (WHO) published an analgesic treatment model that described in detail the appropriate way to escalate therapy in chronic pain associated with cancer [8]. This stepwise model focused on the incremental escalation of treatment from non‐ opioid analgesics to low‐strength opioids and eventually to medium‐ or high‐strength opi‐ oids. Since its publication this model has been adapted into the treatment of all types of pain including acute, chronic and noncancer pain [9]. Many attribute this to the increased opioid utilization for the management of all types of pain [10]. Additionally, many argue that opioid medications are being over utilized and the stepwise approach, while simple, is not the most ideal method in treating chronic pain. Even if the stepwise model is not perfect in its original form, several key components should be considered when implementing or modifying an analgesic treatment regimen [9].

Whether the patient has acute or chronic pain, a couple of components of the WHO's stepwise approach are critical to follow no matter the circumstance [9]. These key aspects include that the prescriber should utilize oral medications whenever possible, prescribe analgesics at fixed intervals dictated by their duration of action, the specific analgesic chosen should be dependent on pain intensity and its effect should be evaluated by a validated pain intensity scale [8]. When looking at the complete analgesic regimen, it should be uniquely tailored to the individual and once a regimen is established, a written personal program should be given to the patient, so they can be held accountable to taking medications at their appropriate times and others (family, friends and medical professionals) know how they take their medications in case of emergency. While these components should be cemented in the care of any patient with low back pain, the ideal stepwise escalation, de‐escalation or type of adjuvant medication depends upon the type of pain being treated and may not follow the originally proposed WHO's step‐ wise approach [9].

Several recommendations have been suggested for the alteration of the WHO's stepwise approach to pain [9]. The first is that when dealing with acute pain, it is sometimes necessary to start at a higher step than the first step of the ladder. This means that opposed to starting with a nonopioid agent alone, it may be necessary to start therapy with a weak, moderate or even strong opioid in addition to a nonopioid agent. However, because most acute pain resolves or markedly improves in a short period of time, there should be an emphasis on early alteration of the analgesic regimen. Rarely are opioids needed for longer than 7 days to treat acute pain [6]. The one major stipulation to treating acute pain in this way (skipping steps on the WHO's ladder) is that the provider is encouraged to rapidly step down the ladder or de‐ escalate therapy as pain diminishes or side effects are too severe. This requires a practitioner to have very close follow‐up and may not be appropriate in all settings. This recommendation is not originally recommended by the WHO, but it is feasible when considering the acute pain process and the need to wean patients from regimens containing strong opioids [9].

As the patient transitions from an acute pain process to a chronic pain state (1–3 months), it is import to reassess the analgesic regimen. If de‐escalation has not been performed, it should be done at this point to ensure that the patient is only prescribed the minimal amount of medi‐ cations required to control their pain. When escalating in a stepwise manner, the cause and type of pain should be considered. The pain regimen should focus on nonopioid analgesics with nonsteroidal anti‐inflammatories (NSAIDs) if the pain is caused or exacerbated by an inflammatory process. Adjuvant medications targeting neuropathic pain should be initiated and optimized at this time if there is a component of neuropathic pain [9]. Only when nono‐ pioids and adjuvant medications have been fully optimized, an opioid should be scheduled at a fixed interval. Nonpharmacologic and nonopioid medications are preferred for chronic pain [6]. If the pain requires opioids, a weak opioid should be trialed first before escalating to a moderate or strong opioid [8, 9]. To appropriately escalate therapy, it is necessary to under‐ stand the specific attributes of each analgesic medication (nonopioids, opioids and adjuvants) so that the patient receives the maximum benefit while minimizing the potential for harm and side effects.
