Combination Therapies

联合治疗
（这里纠正一下，combine，和combination的发音不一样）

Guidelines suggest that when monotherapy is ineffective, multiple agents
may be employed. The rational use of polypharmacy should include drugs that act at different sites in the pain signaling process and ideally have antagonistic adverse effects. Controlled trials have found that gabapentin and nortriptyline（去甲替林）, gabapentin（加巴喷丁） and morphine, and nortriptyline and morphine provide superior benefit than either drug alone for neuropathic pain. In patients with
chronic low back pain, however, gabapentinoids appear to be of limited value with an unimpressive benefit-risk ratio.

Psychological Treatment

心理疗法
The relationship between pain and psychopathology is complex. The lifetime prevalence of coexisting psychiatric illness in chronic pain patients ranges from 50% to over 80%. Between 30% and 60% of chronic pain sufferers experience symptoms of depression, making it the most common comorbidity. For anxiety disorders and substance abuse, co-prevalence rates are around 30% and 10 to 15%, respectively. But whereas it is widely acknowledged that chronic pain can predispose patients to depression, anxiety, substance abuse, and suicide, what is less commonly appreciated is that coexisting psychopathology is a
strong predictor for the development of chronic pain after an acute pain episode, (e.g., back pain episode, surgery) and is associated with poorer treatment outcomes.
It is incumbent upon practitioners to screen all pain patients for psychological conditions that can adversely impact treatment. Not only major psychiatric conditions such as depression and generalized anxiety, but also maladaptive behaviors and secondary diagnoses such as somatization disorder and poor coping skills, can negatively influence treatment.
Relaxation techniques such as biofeedback（生物反馈） and guided imagery have proven effective in a wide array of acute and chronic pain conditions, but may be especially useful in individuals with high levels of anxiety. Cognitive behavioral therapy（认知行为疗法） is a structured form of psychotherapy predicated on the replacement of negative thought patterns and behaviors with more constructive ones.
This treatment enhances inhibitory pain signals and can also be effective for associated symptoms such as fatigue（疲劳） and insomnia（失眠）. Ideal candidates include motivated patients in whom distorted thinking (e.g., catastrophization) and counterproductive behaviors amplify pain behavior. Two-year follow-up of a randomized clinical trial of mindfulness-based stress reduction (MBSR) versus cognitive behavioral therapy (CBT) or usual care for chronic low back pain found that significant between-group differences were sustained only between CBT and usual care; there was some diminution of superior effects of MBSR relative to usual care after 1 year. In patients with personality disorders and ingrained maladaptive behaviors, long-term psychotherapy may be necessary.