Would Lyrica (pregabalin), Celebrex (celecoxib), or Butrans (buprenorphine) be more suitable for managing chronic back pain in this patient?

Management of Chronic Back Pain: Medication Selection

For this 59-year-old female with chronic back pain, Lyrica (pregabalin) would be the most appropriate choice among the three options due to its established efficacy for neuropathic pain components and better safety profile compared to opioids.

Medication Assessment

Current Medication Review

The patient is currently on multiple medications including:

• oxycodone 5mg (opioid)
• lorazepam (benzodiazepine)
• topiramate (anticonvulsant)
• sertraline (antidepressant)
• quetiapine (antipsychotic)
• pramipexole (dopamine agonist)

This polypharmacy situation requires careful consideration when adding new pain medications.

Evidence-Based Medication Selection

1. Lyrica (Pregabalin)

   • Pregabalin has strong evidence (Category A1) for neuropathic pain relief 1
   • For chronic back pain with neuropathic components, pregabalin has demonstrated effectiveness in pain reduction 1
   • Common side effects include dizziness, somnolence, and peripheral edema 1
   • May be particularly beneficial for patients with sleep disturbances due to pain 2

2. Celebrex (Celecoxib)

   • NSAIDs like celecoxib provide effective pain relief for back pain (Category A2 evidence) 1
   • Appropriate for inflammatory components of back pain 1
   • Risk of gastrointestinal, renal, and cardiovascular side effects with prolonged use 3
   • Limited duration (up to one week) is recommended for safety 3

3. Butrans (Buprenorphine)

   • Transdermal opioids can provide relief for back pain for periods of 2 weeks to 3 months (Category B2 evidence) 1
   • Opioids should only be used as a last resort and for very limited duration 3
   • The patient is already on oxycodone, and adding another opioid increases risk of adverse effects
   • CDC recommends avoiding opioids as default treatments for pain 3

Decision Algorithm

1. Assess pain characteristics:

   • If predominantly neuropathic (burning, shooting, electrical sensations) → Pregabalin
   • If predominantly inflammatory (pain with movement, morning stiffness) → Celecoxib
   • If severe pain unresponsive to other treatments → Consider buprenorphine only after other options fail

2. Consider patient-specific factors:

   • Current medications: Patient already on opioid therapy (oxycodone) and topiramate (anticonvulsant)
   • Comorbidities: Potential respiratory concerns (using albuterol)
   • Age: 59-year-old with increased risk for medication side effects

Recommendation Details

Pregabalin (Lyrica) is recommended for the following reasons:

• Demonstrated efficacy for chronic back pain with neuropathic components 1, 4
• May help reduce or eliminate the need for opioids 5
• Can improve sleep quality, which is important given the patient's use of eszopiclone and quetiapine for insomnia 2
• Combination therapy with pregabalin and celecoxib could be considered if monotherapy is insufficient 6

Important Considerations

• Drug interactions: Monitor for additive CNS depression with lorazepam, eszopiclone, quetiapine, and oxycodone
• Dosing: Start with low dose (75mg twice daily) and titrate based on response and tolerability
• Monitoring: Assess for excessive sedation, dizziness, and peripheral edema
• Opioid reduction: Consider using pregabalin as part of an opioid reduction strategy 5

Pitfalls to Avoid

• Adding Butrans (buprenorphine) when the patient is already on oxycodone could increase risk of respiratory depression and other opioid-related adverse effects
• Long-term NSAID use (Celebrex) increases risk of cardiovascular, renal, and gastrointestinal complications
• Failing to address the neuropathic component of chronic back pain, which may be significant in this patient

The evidence suggests that for this patient with chronic back pain who is already on multiple CNS-active medications including an opioid, pregabalin offers the best balance of efficacy and safety among the three options presented.