New guidelines offer five first-line treatments for neuropathic pain

By Karla Gale

NEW YORK (Reuters Health) - Opioids, tricyclic antidepressants, gabapentin, topical lidocaine and tramadol are appropriate for initial treatment of neuropathic pain, an international panel of investigators reports in the Archives of Neurology for November.

And when medication fails to relieve symptoms, neurosurgical interventions are increasingly successful, Dr. Cole A. Giller maintains in a second report in the Archives.

Dr. Robert H. Dworkin, at the University of Rochester School of Medicine and Dentistry, New York, and participants in the Fourth International Conference on the Mechanisms and Treatment of Neuropathic Pain reviewed published information to develop treatment recommendations for patients with neuropathic pain.

"Patients in pain have to be recognized and treated as assertively and as appropriately as soon as possible" to increase the likelihood that treatment will be successful, co-author Dr. Charles R. Argoff told Reuters Health. When deciding on treatment, physicians should consider a medication’s efficacy, cost, side effects, ease of use, and drug-drug interactions.

Up to 50% of primary care providers consider nonsteroidal anti-inflammatory drugs (NSAIDs) an appropriate first line treatment for neuropathic pain. But "NSAIDs are not effective for this type of pain, and they pose a significant risk for side effects," said Dr. Argoff, a faculty member at New York University Medical School. However, patients with comorbid nonneuropathic pain may benefit if an NSAID is added to the treatment regimen, he said.

One option is an opioid drug. "Old teachings that neuropathic pain is resistant to opiates is nonsense," Dr. Argoff said. When an opiate is used as treatment for medical conditions, "it is extraordinarily unlikely that the patient will become a drug addict."

The 5% lidocaine patch (Lidoderm, Endo Pharmaceuticals) is FDA approved for treatment of postherpetic neuralgia. "A large multicenter trial has also showed that it could be used for low back pain," Dr. Argoff added, and he has found it useful for the treatment of other localized pain conditions.

If physicians are not comfortable with treating neuropathic pain, Dr. Argoff advises referral to "a neurologist, an anesthesiologist, or a podiatrist, anyone with skill in pain assessment, diagnosis and treatment."

In his article, Dr. Giller outlines the major neurosurgical interventions for neuropathic pain. Electrical stimulation of the spinal cord, motor cortex, and deep brain often precedes ablative procedures.

Nowadays, radiofrequency is most commonly used for ablative techniques, he notes, because of its ability to precisely control lesions size. Another option is long-term intraspinal drug delivery, useful for cancer pain as well as other benign pain types.

Arch Neurol 2003;1524-1534,1537-1540.