Neuropathic pain

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  • 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


  • 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)
  • 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


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