Management of Chronic Refractory Cough and Back Pain

Introduction to Alternative Therapies

The American College of Chest Physicians recommends multimodality speech pathology therapy as the primary treatment for refractory chronic cough when gabapentinoids cannot be used, with Grade 2C evidence 1, 4
Multimodality speech pathology therapy includes patient education about cough mechanisms, cough suppression techniques, vocal hygiene training, and psychoeducational counseling, and has demonstrated objective reductions in cough frequency and improvements in quality of life 2, 5, 6
For back pain, the American College of Physicians recommends tricyclic antidepressants as the first-line alternative to gabapentinoids, with established efficacy and fewer central nervous system side effects 3

The American College of Chest Physicians guidelines recommend reassessing benefits and risks at 1 week, then monthly before continuing opiate therapy for chronic refractory cough 2, 5, 7
Low-dose slow-release morphine (5 mg twice daily) should be considered when speech pathology therapy fails and cough severely impacts quality of life, with a mean increase of 3.2 points in Leicester Cough Questionnaire scores 2, 6
Assess for GERD-related symptoms, as resolution of GERD can lead to clinically significant improvement in cough (mean LCQ improvement from 14.3 to 17.9) 5, 6

Tricyclic antidepressants (TCAs) are the recommended first-line alternative to gabapentinoids for chronic low back pain, with a starting dose of 10-25 mg at bedtime and slow titration 3
NSAIDs are appropriate for both acute and chronic low back pain, particularly when inflammatory components are present, and topical NSAIDs, lidocaine, or capsaicin can be considered for localized back pain 3, 6
Skeletal muscle relaxants, such as tizanidine, can be considered for short-term relief of acute exacerbations, but should be used with caution due to central nervous system adverse effects 3

For chronic refractory cough, initiate multimodality speech pathology therapy, evaluate and treat GERD if symptoms present, and consider low-dose slow-release morphine (5 mg twice daily) if inadequate response after 4-6 weeks and quality of life severely impaired 1, 2, 4, 5, 6
For back pain, start TCA (amitriptyline or nortriptyline 10-25 mg at bedtime), titrate slowly, and consider short-term skeletal muscle relaxant (tizanidine preferred) or NSAID if no contraindications 3

For cough, monitor quality of life using validated tools, and reassess risk-benefit at 1 week and monthly if using opiates 2, 5
For back pain, assess response after 4-6 weeks, monitor for TCA side effects (anticholinergic effects, sedation, cardiac effects), and avoid medications requiring renal clearance due to impaired renal function 3