Treatment Strategy

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Effective pain management in these cases requires ongoing evaluation, patient education, and reassurance. Diagnostic evaluation of treatable underlying conditions (e.g., spinal cord compression, herniated disc, neoplasm) should continue concurrently with ongoing pain management efforts. Patients should be provided with education regarding the natural history of their condition and realistic treatment expectations (e.g., current treatments are not curative and analgesia is rarely complete). Unfortunately, as much as we would like, no single drug or therapeutic modality works for all neuropathic pain states. Given the multiplicity of eti-ologic causes, diversity of pain mechanisms involved, and individual patient circumstances, treatment regimens must be individualized.

Treatments with the lowest risk of adverse effects should be tried first. Evidence supporting conservative nonpharmacologic treatments (e.g., physiotherapy, exercise, transcutaneous electrical nerve stimulation, CBT, acupuncture) is limited; however, given their presumed safety, nonpharmacologic treatments should be considered whenever appropriate. Simple analgesics (e.g., acetaminophen, NSAIDs) are usually ineffective in pure neuropathic pain but may help with a coexisting nociceptive condition (e.g., sciatica with musculoskeletal low back pain). Additionally, early referrals to a pain clinic for nerve blocks or other interventional therapy may be warranted in some cases to facilitate physiotherapy and pain rehabilitation.

Needless to say, neuropathic pain is best managed with a multidisciplinary approach; however, several different treatments can be initiated in the primary care setting and a simplified treatment algorithm is outlined in Table 23.6.

Despite the previously noted treatment limitations, it is important to remember that even a 30% pain reduction is clinically important to patients (Farrar et al. 2001). Other than analgesia, factors to consider when individualizing therapy include tolerability, other benefits (e.g., improved sleep, mood, and quality of life), low likelihood of serious adverse events, and cost-effectiveness to the patient and the healthcare system.

Table 23.6 Algorithm for the management of neuropathic pain.

Step 1 Step 2

Step 3

Pain assessment, history and physical examination, obtain release of information to review previous diagnostic studies and treatment records

Consider nonpharmaco logic modalities - i.e., physiotherapies, psychological interventions such as cognitive behavioral therapy, bio/neuro-feedback, or early referral for nerve blocks in some cases to facilitate rehabilitation in complex regional pain syndromes. Initiate first-line monotherapy (gabapentin or pregabalin or tricyclic antidepressant (TCA) or serotonin-norepinephrine reuptake inhibitor (SNRI)

Response

Ineffective or not tolerated

Partial treatment response

Step 4

Switch to alternative first-line ding monotherapy (TCA or SNRI or gabapentin or pregabalin)

Consider adding first-line drug (TCA or SNRI or gabapentin or pregabalin)

Response

Ineffective or not tolerated

Partial treatment response

Step 5

Initiate monotherapy with tramadol or opioid analgesic, consider use of opioid risk screening tool, medication management agreement, and informed consent

Consider adding tramadol or opioid analgesic, consider use of opioid risk screening tool, medication management agreement, and informed consent

Response

Ineffective or not tolerated

Step 6

Refer patient to pain specialty clinic for consideration of third-line drugs, interventional treatments, and pain rehabilitation programs

Although little is known about whether the response to one drug predicts the response to another, combining different drugs may result in improved results at lower doses and with fewer side effects. However, if the first oral medication tried is ineffective or not tolerated, one might switch to alternate monotherapy. In the event that all of the first-line oral monotherapies tried are ineffective or poorly tolerated, we would then recommend initiating monotherapy with tramadol or an opioid analgesic.

Many patients with neuropathic pain currently receive drug combinations (Gilron and Bailey 2003), often in the absence of supportive evidence. Nevertheless, clinical experience suggests that poly-pharmacy may be helpful. For example, in a recent RCT, analgesia with a morphine-gabapentin combination was found to be superior to treatment with either drug alone (Gilron et al. 2005). Therefore, in the event of a partial response to any single drug, one could add an alternate drug. Future trials are needed to evaluate optimal drug combinations and dose ratios as well as safety, compliance, and cost-effectiveness. If none of the above treatments is effective or tolerated, referral to a pain clinic is warranted for consideration of third-line drugs, interventional treatments, and pain rehabilitation programs.

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