The World Health Organization (WHO) three-step pain ladder, for example, advocates the inital use of non-opioids, followed by weak opioids and strong opioids based on the severity of pain increases. However, since most chronic pain conditions are multifactorial in nature (e.g. nociceptive and neuropathic components present) effective pain management needs to take into account the underlying mechanisms in order to choose the most targeted treatment.
The majority of severe pain is multi-mechanistic. This means, a neuropathic pain component or signs of increasing chronification cannot be excluded. Beside carefully assessing pain, physicians always have to ask themselves: "Can I exclude a neuropathic component?" Especially for chronic low back pain it is common ground that a neuropathic pain component is the rule rather than the exception.1,2
1 Freynhagen R et al. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin. 2006; 22(10):1911-20.
2 Bennett MI et al. Pain 2012, 153:359-365.