Neuropathic pain

Background

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)
- Antiepileptics - gabapentin, topiramate
- TCAs - amitriptyline, nortriptyline
- Duloxetine (especially if TCAs contraindicated)
- Pregabalin
- NSAIDs and Tylenol
Second line medications (temporary relief, not long term)
- Tramadol
- Muscle relaxants - cyclobenzaprine, methocarbamol, diazepam
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.