Neuropathic Pain: Insights for the Practitioner

Sean Mackey, MD, PhD, CPE

Treatment of neuropathic pain requires a multidisciplinary plan made up of multiple components. It requires a personalized strategy that engages psychological approaches, procedural approaches, complementary or alternative medicine techniques, physical and occupational therapies, and then also pharmacologic agents. With respect to these, there are medications that are FDA-approved for other treatments that may also have FDA approval for neuropathic pain. Tricyclic antidepressants can be effective for neuropathic pain, serotonin and norepinephrine reuptake inhibitors may be useful, and there are over the counter agents, an interesting group of nutraceuticals that don’t require prescription. A number of these have been shown to have efficacy for neuropathic pain in randomized controlled trials. Agents such acetyl-L-carnitine, alpha-lipoic acid, fish oil—all of these are readily available that our patients can try and also are backed by good RCT trials.

How do we balance the conundrum of opioids? These are medications that can provide great benefit to some people who will get improvements in function and quality of life, but for others can result in misuse, abuse, diversion, addiction, and even death. We’ve learned that pre-exposure depression, anxiety, history of post-traumatic stress disorder, and a tendency to catastrophize make people more vulnerable to persistent use of opioids after exposure. This trifecta of components—negative amplification of pain, rumination of pain, and a sense of helplessness—can predispose somebody when exposed to an opioid or another potentially habit-forming substance to end up using them persistently. That doesn’t mean that we need to screen out those people, but we need to be more vigilant. We need to monitor more carefully. We may need to provide those people who are vulnerable with more education and also try to identify nonopioid approaches for managing their pain.

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