Neuropathic pain management pdf

The magnitude of pain reduction associated with relatively short-term opioid analgesics is at least as great as that obtained with other treatments for neuropathic pain. In a Cochrane Database review of morphine vs placebo for chronic neuropathic pain in adults, Cooper et al.

Cooper concluded that there is insufficient high-quality evidence to support or refute the suggestion that morphine is efficacious in any neuropathic pain condition. Gaskell et al. The associated number needed to treat for an additional beneficial outcome was 5. As a result, Gaskell et al. Furthermore, in conducting their literature search, Gaskell et al.

In , Finnerup et al. In the case of opioids, the NNT ranged from 2. The combined NNH for opioids for all etiologies was The authors concluded that the lack of proven long-term effectiveness and the high risk for adverse effects called for alternative treatment options to target chronic neuropathic pain. More recently, Finnerup et al. CDC and Canadian guidelines on use of opioids in noncancer chronic pain recommend optimization of nonpharmacological and non-opioid-based therapies [ , ].

Commencement should be with immediate-release forms of the drug with the aim of utilizing the lowest possible dose. The patient is converted to slow release once a stable, effective dose has been achieved. A trial of therapy should occur for one to four weeks, after which the benefits relative to the risks should once again be reviewed.

This should occur every three months [ ]. Targeted drug delivery is used to deliver medications directly to their site of action at the dorsal horn of the spinal cord, bypassing the first pass effect and the blood—brain barrier.

This significantly increases the potency of the medication, allowing much smaller doses to be used [ ]. Recommendations for the use of targeted drug delivery vary between organizations.

The APS guidelines state that for nonradicular pain there is insufficient evidence to evaluate benefits of intrathecal therapy with opioids or other medications. However, no reference is made to radicular or neuropathic pain for the use of TDD [ 17 ]. TDD is included in this algorithm as a management option for patients who are considered to suffer refractory pain:. These patients have moved through the preceding algorithm, all psychosocial factors have been addressed, and they have failed medication-based therapies, neurostimulation, and low-dose opioids.

In certain circumstances, it may be appropriate to proceed directly to TDD following failed neurostimulation. The PACC recommendations place TDD after neurostimulation in its noncancer and cancer pain algorithm when the pain is well localized, has a clear diagnosis, is largely neuropathic or mixed, and neurostimulation fails or cannot adequately cover the areas of pain [ 15 ].

Before initiating TDD, patients must undergo an intrathecal medication trial. Although multiple dosing strategies exist, there are no data to support superiority. For effective therapy, patient selection is crucial.

Patients with localized pain are likely to respond best to TDD e. This is due to the limited spread of drugs in the cerebrospinal fluid. There are some patients who may benefit from a trial of TDD before neurostimulation, but in general the higher safety profile of neurostimulation places it ahead of TDD in a neuropathic pain algorithm.

However, in most cases, TDD should be considered after low-dose oral opioid therapy has failed to provide adequate pain relief. Neuropathic pain is highly debilitating, difficult to diagnose, and only partially responsive to nearly all treatment. A multidisciplinary, structured stepwise approach is needed to decrease pain and attain an acceptable quality of life for patients. We propose a treatment algorithm to guide the primary physician through a step-by-step, time-limited treatment process.

Firstline treatment includes multidisciplinary care in conjunction with TCAs, gabapentanoids, SNRIs, topical lignocaine, and capsaicin. These should be trialed over an average of four to six weeks; if acceptable pain relief is not achieved, they should be ceased, and progression to the next medication or next line of treatment should occur. Second-line treatment included tramadol and combination therapy. Tramadol is currently recommended for exacerbation of symptoms only, with caution in the elderly.

Combination therapy is common in the treatment of neuropathic pain; its use should be on a trial basis for the duration of the second medication, and the patient should be followed for increased side effects and lack of efficacy. For patients who fail to respond to first- and second-line therapies, referral to a specialist pain center is recommended.

Third-line treatment includes interventional therapies such as epidural injection, pulsed radiofrequency, sympathetic blockade, and adhesiolysis. They should be considered if first- and second-line therapies have failed to achieve adequate pain relief or before proceeding to neurostimulation. That said, it is important to note that all interventional therapies are limited to specific indications.

Neurostimulation is proposed as a fourth-line treatment before commencement of low-dose opioids. Low-dose oral opioids are recommended as fifth-line due to the limited duration of efficacy and the significant risk of side effects. Commencement should be with immediate-release medication and should be titrated to the lowest possible dose.

The patient should then be converted to slow-release opioids. Caution should be taken when exceeding 50 MED of morphine, and 90 MED should be exceeded only with significant justification. The authors wish to thank Linda Johnson, PhD, an independent consultant, for assistance with writing, editing, and manuscript preparation.

Funding sources: This study was funded by Abbott. Conflicts of interest: Dr. Hanes: Abbott, Medtronic Consultant. National Center for Biotechnology Information , U. Pain Med. Published online Jun 1. Author information Copyright and License information Disclaimer. For commercial re-use, please contactjournals.

This article has been cited by other articles in PMC. Abstract Background The objective of this review was to merge current treatment guidelines and best practice recommendations for management of neuropathic pain into a comprehensive algorithm for primary physicians.

Results The algorithm provides a comprehensive treatment pathway from assessment to the provision of first- through sixth-line therapies for primary care physicians. Conclusions The presented treatment algorithm provides clear-cut tools for the assessment and treatment of neuropathic pain based on international guidelines, published data, and best practice recommendations.

Open in a separate window. Figure 1. Comprehensive algorithm for the management of neuropathic pain. Methods All guidelines focused on the assessment of neuropathic pain highlight the use of a comprehensive history and examination with reliance on clinical judgment in the interpretation of screening tools and investigations [ 1 , 6 , 7 ].

History Neuropathic pain stems from a wide variety of causes that can be broadly organized into two basic categories: peripheral and central etiologies [ 19 ].

Quantifying the Consequences of Pain Neuropathic pain can have a significant effect on mood and quality of life [ 26 , 27 ]. Examination No single sign or physical finding is diagnostic of neuropathic pain.

Results Firstline Treatment Pain is more than just an unpleasant sensation. Multidisciplinary Team Care Multidisciplinary care is highlighted as a key component of the management of neuropathic pain by a number of guidelines [ 1 , 13 , 42 , 44 ]. Pharmacological Management Medications form the basis of first- and second-line therapy for neuropathic pain Table 1.

Table 1 First- and second-line medications for neuropathic pain. Serotonin and norepinephrine reuptake inhibitors Duloxetine Start at 30 mg PO daily. Renal or liver disease Venlafaxine Start at Apply to site of pain 12 hours on, 12 hours off.

Max of three patches at one time. Aim for lower doses of both. Gabapentinoids Gabapentanoids include gabapentin and pregabalin. Topical—Lidocaine, Capsaicin, and Transdermal Substances The side effect profile of TCAs, SNRIs, and gabapentanoids requires extremely cautious dosing in many patients, especially the elderly, with some patients having side effects with the lowest available doses.

Transdermal Substances Only lidocaine and capsaicin are referred to in the various international guidelines on management of neuropathic pain. Second-Line Treatment Combination Therapy No one drug is effective for all patients, and, as seen above, pain relief is usually partial and side effects limit tolerability [ 13 ].

Tramadol and Tapentadol Tramadol is considered second-line treatment in most guidelines [ 3 , 8 , 9 , 13 ] but firstline in acute neuropathic pain, cancer-related neuropathic pain, and intermittent exacerbations of neuropathic pain. Interventional Therapies Epidural Injection. Fifth-Line Treatment Low-Dose Opioid Opioids have been recommended as second- [ 9 ], third- [ 2 , 3 , 8 ] or fourth-line therapy [ 14 ] for neuropathic pain.

Sixth-Line Treatment Targeted Drug Delivery Targeted drug delivery is used to deliver medications directly to their site of action at the dorsal horn of the spinal cord, bypassing the first pass effect and the blood—brain barrier. Conclusions Neuropathic pain is highly debilitating, difficult to diagnose, and only partially responsive to nearly all treatment. Acknowledgments The authors wish to thank Linda Johnson, PhD, an independent consultant, for assistance with writing, editing, and manuscript preparation.

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Descriptive statistics were used to summarize socio-demographic and pain characteristics, comorbidities and medication use of participants. Mann Whitney test and Chi-squared test were used to examine the differences between the two groups inpatient and outpatient groups. A Tobit regression model was used to estimate factors associated with satisfaction toward pain management, censoring from 19 and in the satisfaction score.

With the threshold of 0. In a total of patients, the mean age was Proportion of co-morbidities in outpatients was higher than inpatients Pain characteristics of participants were illustrated in Table 2 , more than one third of the participants reported the sensation of pain in at least two locations Regarding pain intensity at the time of the interview, moderate pain was observed in Most participants commonly reported pain at head-face-neck Among three routes of pain medication administration, the majority was oral route The level of patient satisfaction toward pain management is shown in Table 3.

Table 4 summarizes the Tobit regression results exploring factors associated with the total satisfaction score. The results show that the number of pain locations, pain intensity, current smoking and having health insurance were significantly associated with the total satisfaction score.

In more detail, those who perceived severe pain tended to be less satisfied with the pain management than those without it Coef: 4. The purpose of this study was to assess the level of patient satisfaction toward treatment of chronic pain and to explore the relationship between satisfaction and some factors. To the best of our knowledge, this is the first descriptive study performed in older patients which also evaluated patient satisfaction in many aspects in the context of Vietnam.

Thus, the results of this present study render empirical findings which are the premise for further studies. In particular, our study indicated that side effects of current pain relievers was the most satisfactory aspect of pain treatment. Rating of satisfaction with medical care was also high in this study. The finding was in congruence with previous literature on patient engagement and satisfaction with care. Meanwhile, out of the seven dimensions of PTSS scale, information about pain and its treatment obtained the highest mean score, suggesting that it was the most dissatisfactory aspect of pain treatment in this population.

This result might vary in different populations. According to results from Wong et al, the least satisfactory aspect in pain treatment was impact of the current pain medication. Moreover, to date, there has not been an official guideline for pain treatment in Vietnam, especially in geriatric care. Furthermore, in developing countries, overcrowding of patients in major hospitals and comorbidities in older patients lead to limited time for examination and to give information on pain management to each patient.

In our results, current pain medication, especially in efficacy subscale was also a dissatisfactory aspect of pain treatment. Patients responded that they were not satisfied with the time it takes for the pain relievers to work, the level and duration of pain relief.

Thus, it would be more prudent for healthcare providers to assess individual needs and expectations for pain relief by discussing those with older patients. Of note, outpatients were less satisfied with information provided, the impact of current medication, and the pain management in general compared to inpatients. We hypothesize that outpatients tend to self-treat at home after receiving a prescription from a physician, so they might not receive the necessary information on a regular, timely basis like inpatients.

Pain treatment might be more effective for inpatients due to the aggressive interventions of healthcare workers. The finding showed that For these patients, providing sufficient information and treatment information is essential. The regression model showed that patients who perceived severe pain tended to be less satisfied with the pain management than those with no pain. The relationship between the pain intensity and satisfaction in our study is consistent with numerous other studies.

A combination of inadequate treatment, high pain intensity, and unmet needs in pain relief and limitation of healthcare system may lead to dissatisfaction with services. This study suggests several implications. First, a training program should be designed and provided to geriatric health professionals as well as physicians and nurses to improve the effectiveness of pain treatment in older patients.

Second, comprehensive assessment of pain characteristics as well as satisfaction with pain treatment should be evaluated regularly in clinical practice. Feedback from patients may be used to alter and improve the quality of health care delivery. Third, hospitals and healthcare professionals should create conditions for older patients to be provided with complete information about pain and pain treatment.

A study which assesses knowledge and attitude of health care providers regarding pain management in older people should be conducted in the future.

Our study is subject to several limitations. First, this project was conducted in a geriatric hospital which reduced our ability to find out the factors associated with satisfaction regarding pain management for older people.

Little information about the origins of pain was also a limitation of the research. Additionally, this limitation decreases our generalizability, implying that we should be cautious when applying our findings to other settings. Besides, the nature of a cross-sectional design does not allow to draw causal relationships between variables and the outcome of interests.

Future studies employing a longitudinal design could help address these limitations. Also, since the patients were allowed to refuse to answer any questions during the interview, data may be missing, thus, it might affect the generalizability of the findings.

However, dissatisfactory dimensions remained, including pain information provided and efficacy of current pain medication. Intensive training regarding pain in geriatric care, health education communication for older people and improved quality of medical services should be performed to ensure the quality of pain management, especially in older populations. The datasets of this study are available from the corresponding author on reasonable request. Written informed consent was obtained from all participants.

This study complied with the Declaration of Helsinki. All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.

The author reports no potential conflicts of interest in this work. National Center for Biotechnology Information , U. Journal List Patient Prefer Adherence v. Patient Prefer Adherence. Published online Oct 6. Author information Article notes Copyright and License information Disclaimer. Received Jun 3; Accepted Aug This work is published and licensed by Dove Medical Press Limited. By accessing the work you hereby accept the Terms.

Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4. Abstract Purpose The high prevalence of chronic pain and difficulties in pain management in older people are challenging for healthcare providers globally. Results The mean total satisfaction score was 1. Keywords: chronic pain, elderly, pain management, satisfaction, Vietnam.

Introduction Chronic pain is one of the most common symptoms in older people that causes a significant burden on health care in both developed and developing countries. Data Collection Face-to-face interviews were performed in a private room to ensure a comfortable atmosphere and confidentiality. Results In a total of patients, the mean age was Table 1 Socio-Demographic Characteristics of Participants.

Open in a separate window. Table 2 Pain Characteristics of Participants. Discussion The purpose of this study was to assess the level of patient satisfaction toward treatment of chronic pain and to explore the relationship between satisfaction and some factors.

Funding Statement There was no funding for this analysis. Data Sharing Statement The datasets of this study are available from the corresponding author on reasonable request. Author Contributions All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.

Disclosure The author reports no potential conflicts of interest in this work. References 1. A classification of chronic pain for ICD A systematic review of the prevalence and measurement of chronic pain in asian adults.

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