Neuropathic pain: Difference between revisions
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*Do not consider starting patients on medications unless they will definitely obtain good follow-up | *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) | *First line medication options (all have NNT from ~2-3 or better) | ||
** | **[[Antiepileptics]] - gabapentin, topiramate | ||
**TCAs - amitryptyline, nortriptyline | **[[TCAs]] - [[amitryptyline]], [[nortriptyline]] | ||
**Duloxetine (especially if TCAs contraindicated) | **Duloxetine (especially if TCAs contraindicated) | ||
**Pregabalin | **Pregabalin | ||
**NSAIDs and | **[[NSAIDs]] and [[Tylenol]] | ||
*Second line medications (temporary relief, not long term) | *Second line medications (temporary relief, not long term) | ||
**Tramadol | **[[Tramadol]] | ||
**Muscle relaxants - cyclobenzaprine, methocarbamol, diazepam | **Muscle relaxants - cyclobenzaprine, methocarbamol, [[diazepam]] | ||
*Refer to pain specialist for multidisciplinary approach | *Refer to pain specialist for multidisciplinary approach | ||
*Pain specialists can offer (discussion with patient in ED): | *Pain specialists can offer (discussion with patient in ED): | ||
| Line 20: | Line 20: | ||
**Radiofrequency ablations | **Radiofrequency ablations | ||
**Spinal implants | **Spinal implants | ||
**Determination of long-term | **Determination of long-term opioids | ||
**Pain psychology | **Pain psychology | ||
**Spinal manipulation | **Spinal manipulation | ||
Revision as of 23:43, 14 July 2016
Background
- Neuropathic pain responds best to multifaceted approach - not to opioids
- If opiates 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 opiates/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 - amitryptyline, nortriptyline
- Duloxetine (especially if TCAs contraindicated)
- Pregabalin
- NSAIDs and Tylenol
- Second line medications (temporary relief, not long term)
- 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.