Neuropathic pain

Background

• Neuropathic pain responds best to multifaceted approach - not to opioids
• If opioids can be avoided, it helps primary care providers and pain management specialists create a better regimen
• Cornerstone of pain management is activity (exercise, PT, aquatherapy), but opioids/benzodiazepines restrict this

Management

• Do not consider starting patients on medications unless they will definitely obtain good follow-up
• First line medication options (all have NNT from ~2-3 or better)
  • Antiepileptics - gabapentin, topiramate
  • TCAs - amitriptyline, nortriptyline
  • Duloxetine (especially if TCAs contraindicated)
  • Pregabalin
  • NSAIDs and Tylenol
• Second line medications (temporary relief, not long term)
  • Tramadol
  • Muscle relaxants - cyclobenzaprine, methocarbamol, diazepam
• Refer to pain specialist for multidisciplinary approach
• Pain specialists can offer (discussion with patient in ED):
  • Injections - trigger point, epidural steroid injections, facet injections, medial branch blocks, joint steroid injections
  • Radiofrequency ablations
  • Spinal implants
  • Determination of long-term opioids
  • Pain psychology
  • Spinal manipulation
• Lifestyle changes
  • Weight loss
  • Sobriety, reduction of polypharmacy, smoking cessation
  • Exercise, avoidance of bed rest, core strengthening

References

Rathmell JP. A 50-year-old man with chronic low back pain. JAMA. 2008;299(17):2066-77.