Sirs: Spasticity and pain are common features of multiple sclerosis (MS) [6]. Because pain may be relieved by anti-spasticity measures, treatment of spasticity should precede specific pain management. About 20 % of MS patients are either intolerant to oral medications or continue to have significant spasticity despite maximal oral dosage. These patients are optimally managed with continuous intrathecal baclofen infusion (ITB) administered via a surgically implanted programmable pump, a FDA-approved treatment modality [7, 8]. For patients with pain associated with spasticity, ITB therapy usually provides adequate relief of both symptoms. Apart from spasticity other pain syndromes may occur in MS. Neuropathic pain is the most common, may be disabling in severity and resistant to oral pain medications. Intrathecal morphine (ITM) is an established form of treatment for intractable pain syndromes and is beneficial in the majority of such patients [2, 4, 5]. In this retrospective study, we investigated the long-term efficacy and safety of ITB/ITM combination in nine MS patients [3]. All nine patients were resistant or intolerant of maximal oral anti-spasticity medications and all classes of standard oral pain medications including narcotics (Table 1). Patients (all with Ashworth scores of 4 or greater) were first assessed for response to ITB. A screening test dose of 75 mg of baclofen was injected into the CSF and this resulted in complete relief of spasticity with greater than a 2 point drop on the Ashworth spasticity score. All patients underwent successful surgical implantation of Medtronic programmable pumps. Postimplantation, ITB dose was optimized for relief of spasticity (Table 1). All clinical assessments for spasticity were graded according to the Ashworth Spasticity Scale [7]. Although with ITB treatment patients had a decrease in pain associated with spasticity, neuropathic pain was unaffected and patients with Visual Pain Analogue Scale Scores (VPASS) [3] of 8 or greater were selected for addition of ITM to ITB. Because morphine has an anti-spasticity effect and both agents depress respiration, doses of medications were initially conservative. The mix was set to deliver a rate of half the previous daily dose of baclofen and 500 mg of morphine a day. Subsequent dose and mixture adjustments were done according to patient response to pain (utilizing VPASS) and spasticity (Ashworth score/functional assessment). This study was approved by the Institutional Review Board (IRB) of St. Luke’s-Roosevelt Hospital. All nine MS patients who had persistent severe pain despite optimal relief of spasticity with ITB therapy had excellent analgesic responses to the addition of ITM. The mean VPASS scores for the nine patients decreased from 8.6 to 1.4 and these responses were sustained over an average of 6.2 years (1–10 years follow-up as shown in Table 2). Therapeutic doses varied widely among individuals with baclofen ranging from 5 to 1200 μg a day and morphine from 800 to 9500 μg a day. In the patient taking 5 μg of baclofen decreasing the dose below this leads to an intolerable degree of spasticity whereas at this dose she has enough tone to transfer. There were no serious adverse effects noted in any of our patients. None of the patients developed respiratory depression. Two of the 9 patients (P04, P08) initially had transient nausea and 2 patients reported worsening constipation (P03, P08), which responded well to a bowel regimen for relief of constipation. One patient developed bilateral lower limb edema (P05), a recognized complication of ITM [1]. In this study, we showed that ITB/ITM in combination has longterm efficacy (mean follow-up period of 6.2 years) in treating patients with intractable pain and spasticity. The shortcomings of this study are the small number of patients, the lack of blinding, and being retrospective.