Drug Combos Do Not Work In Back Pain -But what you might try

It is commonly taught that drug combinations should be used in chronic pain – the most common pain being chronic back pain. Now it has been shown that little is gained from that. Only combo worth mentioning was buprenorphine plus pregabalin – the former is difficult if insurers won’t cover. There are other options that require actually treating the patient.

J Pain. 2019 Jan;20(1):1-15. doi: 10.1016/j.jpain.2018.06.005.
Combination Drug Therapy for the Management of Low Back Pain and Sciatica:
Systematic Review and Meta-Analysis.
Mathieson S et al

  • 27 studies analyzed
  • “Most combinations had no or small effect on pain and disability”
  • Yet Butrans 35 with pregabalin 300 mg/day had profound effect:
    Pota, Vincenzo, et al.
    Combination therapy with transdermal buprenorphine and pregabalin for chronic low back pain.
    Pain management 2.1 (2012): 23-31.

Comment – Butrans is a unique agent which I am now using to treat treatment-resistant depression – one subject that can afford it is astounded just how well it works for mood. Study exist that it can even work in ECT resistant depression:
I wrote about it here:
Using the Pain System to Treat Depression – Buprenorphine

warning: – effect wanes some if drug stopped so plan on using it for longterm chronic pain..

Some time ago our Canadian Indian affairs dept mandated that pain victims had to try Cymbalta, lyrica or gabapentin first for their back pains.

This had to be a joke because effect for example of cymbalta was not clinically relevent:


Gabapentin was found to have no benefit in back pain or sciatica I wrote here:
Gabapentin Fails to Help Back Pain With or Without Sciatica

Pregabalin was reserved for more neuropathic back pain and failed show much except in the butrans study.
pregabalin was found ineffective in sciaticas – acute or chronic:
Mathieson S, Maher CG, McLachlan AJ, et al.
Trial of pregabalin for acute and chronic sciatica.
N Engl J Med 2017; 376: 1111−20.

and so recent review of back pain treatments
Foster, Nadine E., et al.
Prevention and treatment of low back pain: evidence, challenges, and promising directions.
The Lancet (2018).

states” The role of gabaergic drugs, such as pregabalin, is now being reconsidered
after a 2017 trial showed pregabalin to be ineffective for radicular pain”

New treatments out of the box need to be considered for treatment:

One need to look out of the box for treatment options. I first take out the quadratus lumborum

I wrote about it here:
Why All the Quadratus Lumborum Back Pains and How I Treat It

I would mobilize the SI joints –  Dr. Helen Bertrand from UBC contends it is a major issue.

Often the sacral dorsal nerve roots are very tender – S1 just above the psis and s2 and s3 below – Injecting them with botulinum and subsequently injecting these sensitized nerves to semineuolytic 5% lidocaine – will give significant relief ( the lidocaine shots will continue to help some until 12 week when the botulinum effects wear off)

Idea of botulinum came out of study of people left with back pains after multiple back operation – called “rebel Pains”
Bootulinum to tender areas reduced pain 40%
Christophe, Laure, Soline Bellaiche, and Emmanuelle Chaléat-Valayer.
Usefulness of botulinum toxin in local rebel pain after spine arthrodesis.
Annals of Physical and Rehabilitation Medicine 60 (2017): e81.

I find midazolam caudally ( rather than intrathecal) helpful:
Confirmed – Intrathecal (Spinal) Midazolam Gives 1-3 Months Relief in Chronic and Failed Back Pain

In failed back, they were using 0.6 ml of 5 mg/ml. – you get significant sedation but subjects prefer it to steroid epidurals

In just back pain, I use 1- 1.5 mls of 5 mg/ml in 20 mls D5W with beneficial effects without sedational effects

low back facet syndromes, thoracolumbar areas and piriformis need attention as well. For the former I would you activator manipulation and prolotherapy but that is for another write-up.


Dealing with a back is like pealing an onion – as soon as you relieve one issue – other issues become more apparent in the next layer underneath – my list will eventually contain 10+ problems

I hope you found some of this helpful…

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