“It isn't pain…exactly”Treatment of Neuropathic Pain
Discussion Questions and Teaching Guide
Discussion leader: ask the group the numbered, bolded questions. Guide the group to cover the key points bulleted below.
1. What are words that patients commonly use to describe neuropathic pain?
· Patients will usually describe neuropathic pain as burning, tingling, numb, painful to a light touch or like “pins and needles.” Patients will also describe shock-like or other uncomfortable sensations radiating or shooting down an extremity.
· Patients may not identify these sensations as pain, but rather as uncomfortable or “funny” feelings.
2. How are antidepressants used in the treatment of pain?
· The tricyclic antidepressants can provide relief for some neuropathic pain, particularly pain that the patient describes as burning, tingling, numb, painful to a light touch or like “pins and needles.”
· Amitriptyline (ElavilÒ), desipramine (Norpraminâ), and nortriptyline (Pamelorâ) are the most commonly used. Start with 25mg per day. If your patient is frail and elderly, you may wish to recommend starting with 10mg. Increase by 25mg every 3 days until the patient has pain relief or encounters unacceptable side effects. The maximum dose is 150mg per day.
· The selective serotonin reuptake inhibitors (e.g. ProzacÒ, PaxilÒ, ZoloftÒ.) do not appear to be effective for neuropathic pain. However, if patients are depressed, relieving depression may also help to relieve their pain.
· The tricyclic antidepressants may also be helpful for neuropathic pain that is lancinating, shooting, or radiating, and can be tried if anticonvulsants prove ineffective.
3. How are anticonvulsants used in the treatment of neuropathic pain?
· The anticonvulsants can provide relief for some neuropathic pain, particularly pain that is lancinating, shooting, or radiating.
· These drugs should be dosed and monitored exactly as they would be for seizures – starting with a low dose and slowly increasing.
· Anticonvulsants may also be helpful for neuropathic pain that is burning, tingling, numb, painful to a light touch or like “pins and needles”, and can be tried if the tricyclic antidepressants are ineffective.
4. What other treatments may be helpful for neuropathic pain?
· Local anesthetics, either orally (mexilitine) or as an IV or SQ infusion (lidocaine) can be helpful. These are complex medications, which should only be used under the supervision of a pain specialist.
· Capsaicin, which is available without a prescription may help some patients. It causes a burning sensation at the site of administration, which can limit its usefulness for some patients.
· Opioids are considered to be the first line of treatment for neuropathic pain due to cancer. They can also be effective for non-cancer pain. Dose and titrate the opioid as you would for any type of pain. You will know when you have reached the limit of an opioid’s effectiveness if the patient has no increased relief, but has persistent unacceptable side effects.
5. What are some key education issues for patients with neuropathic pain?
· The patient may not define the sensations he or she feels as pain, but rather may refer to them as annoying, or as “funny feelings.” The patient may need reassurance that this constitutes a clinical issue worthy of follow-up.
· The treatment of neuropathic pain can take time. It may be necessary to try several different medications at gradually increasing doses before relief occurs.
· Neuropathic pain may respond to medications we usually do not think of as pain relievers. Patients may be concerned that a clinician that offers an anti-depressant may really believe the pain is “all in the head.” Similarly, patients may be confused about why a seizure medication is prescribed for their pain.
Dahl J, Stevenson K, Gordon D, Ó UW Board of Regents, 2000