Charles E. Argoff, MD

Disclosures

February 12, 2010

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Hi, I'm Dr. Charles Argoff, a Professor of Neurology and Director of the Comprehensive Pain Program at Albany Medical Center in Albany, New York. I'd like to speak a little bit about multimodal therapy.

I do both basic science as well as clinical research, and I think it's fitting to discuss this, because while multimodal therapy is ultimately what we use to apply to patient-related matters, it's rooted in understanding that for any given pain syndrome, there are multiple etiologies. Not etiologies in terms of disk-related disease for chronic low back pain or neuropathic pain, but actual different basic mechanisms that may be going on at the same time.

What we've learned in translating that understanding to clinical care is that no one treatment works equally well for a given person with the same syndromes. So no 2 people with low back pain respond to the same treatment; no 2 people with diabetic neuropathy or postherpetic neuralgia respond to the same treatment. And this may be rooted in a variety of things, including heterogeneity and terms of the mechanisms.

So where does that lead us? That leads us to an understanding that when we treat people clinically and we concentrate, let's say, on pharmacologic therapies -- medical therapies for people with either diabetic neuropathy or postherpetic neuralgia; even osteoarthritis, chronic low back pain, fibromyalgia, or chronic headache -- we may wind up having to use medications that have different mechanisms in order to benefit the person we're treating most effectively.

Where this becomes extremely important is in not putting all our eggs in 1 basket; approaching a patient with the expectation that if we do use pharmacologic therapy, we may very likely have to start with one class of therapy, but [also making] it very clear to the individual we're treating that we may have to add therapies to maximize benefit.

Right now, I'm at the American Academy of Pain Medicine annual meeting in San Antonio, Texas, and there are a lot of exciting developments in multimodal therapy. One is just recognizing that multimodal, or multidrug, therapy may be more effective, or is more effective, in many cases than unimodal, or just 1 kind, of analgesic therapy alone.

Where this becomes important is recognizing that opioid analgesics alone can be very effective [but in some cases not as effective as multimodal therapy]. If we're treating, for example, postherpetic neuralgia or diabetic neuropathy, it's been my clinical experience, as well as published experience, that combining an opioid with a nonopioid such as gabapentin or pregabalin may lead to more effective outcomes at lower doses of each therapy than using an opioid alone.

[It's important to recognize that opioids] have adverse effects at higher doses that may preclude their use or their tolerability, so that when treating somebody you don't expect to have to go to higher doses. You might expect at a certain dose to then add another medication or add another opioid to an established regimen. But this also holds true of combining medications such as tricyclics and gabapentin, so there's evidence now that nortriptyline combined with gabapentin may be more effective than using either alone.

There are some medications are being developed (for example, tapentadol) which have both opioid and nonopioid mechanisms within 1 chemical entity. Tapentadol, which is now available in the immediate-release preparation only, is being investigated; there are data at this meeting in which an extended-release version of tapentadol has been shown to be effective for diabetic neuropathic pain.

What we see is that [tapentadol] has both opioid agonist activity directly as well as the ability to block the uptake of norepinephrine. So it has both a catecholamine- as well as an opioid mechanism, which appears to be effective in the management of various types of both acute and chronic pain.

I feel very strongly about emphasizing the role of multidrug therapy because, too often in my experience, I've had patients referred to me as a pain specialist who are considered failures because they didn't respond to seemingly maximum doses of one medication. And there is an impact on the patient when they're told -- or they believe -- that they're difficult to control, or they fail therapy, or someone says, "I've done everything I can for you." There are instances when people are particularly recalcitrant and hard to treat. But most of the time I find that adding another treatment, and doing so a little sooner, results in a more effective outcome. So I would implore and urge those of you who take care of patients with chronic pain to consider combining therapies early in your treatment, perhaps at doses that may be synergistic with each other, as opposed to using only 1 approach.

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