Effective Treatments for Neuropathic Pain
Question: What is a basic formula for treating neuropathic pain?
Answer: When dealing with a patient who has chronic pain, an important initial consideration is whether or not the patient’s pain consists of, or includes, neuropathic pain. Like all other kinds of pain, neuropathic pain can be treated effectively with opioids,1-3 despite an outdated and now discredited belief that such pain does not respond to opioids. However, neuropathic pain also responds to other categories of drugs, specifically, the centrally acting antiseizure drugs such as gabapentin (Neurontin, others) and pregabalin (Lyrica), tricyclic antidepressants, and the serotonin-norepinephrine reuptake inhibitors duloxetine (Cymbalta) and venlafaxine (Effexor). The FDA has approved gabapentin for treatment of diabetic peripheral neuropathy (DPN) and postherpetic neuralgia (PHN), and pregabalin for fibromyalgia. These drugs are also used (off label) for back pain patients whose pain radiates down his or her leg. When neuropathic pain affects the surface, as in PHN, topical medications such as lidocaine patches (Lidoderm) and capsaicin cream can also be effective.
A classic type of neuropathic pain is DPN. Evidence-based consensus guidelines written by Argoff et al listed preferred medications for the treatment of DPN: 1) First tier: duloxetine, oxycodone CR (OxyContin), pregabalin, and tricyclic antidepressants; 2) second tier: carbamazepine (Carbatrol, others), gabapentin, lamotrigine (Lamictal), tramadol (Ultram, others), and venlafaxine ER. Topical capsaicin and lidocaine are also mentioned.4 First-tier agents should be titrated to maximum tolerated doses, with a goal of at least 50% reduction of pain from baseline. For all first-tier drugs, expect some improvement within three weeks. If no improvement is noted, consider modifying the therapy.4
—Jennifer Schneider, MD, PhD
Internal Medicine, Addiction Medicine, and Pain Management