Summary:  Claudia Hurwitz

Editor:  Jane Standen

 

With Dr Jane Standen, Consultant Anaesthetist and Interventional Pain Specialist, Sydney, Australia

James talks to Dr Jane Standen about neuropathic pain.

Jane is s Consultant Anaesthetist and interventional Pain Specialist. She studied medicine at the University of Sydney and trained in anaesthesia at the Prince of Wales Hospital, Sydney. Subspecialty training in pain management was undertaken at the Michael J Cousins Pain Management and Research Centre at Royal North Shore Hospital.

Jane has expertise in the treatment of both early onset and persistent pain. She specialises in minimally invasive procedures, aiming to reduce pain and enhance quality of life. She practices with an empathetic manner and takes an evidence-based approach.

Jane is an honorary tutor with the University of Sydney Masters in Pain Management and is actively involved in pain management education at the Mater Hospital and Royal North Shore Hospital. She regularly conducts GP educational sessions.

She is appointed at Norwest Private Hospital, the Sydney Adventist Hospital, the Mater Hospital and Royal North Shore Hospital.

 

 

Introduction

Neuropathic pain refers to pain in association with a lesion or disease effecting the somatosensory nervous system.

 

Case – You’re covering the ward after hours and you receive a call to review a 65 year old male with foot pain. He has presented with Peripheral Vascular Disease (PVD), an angiogram shows arterial narrowing. He is on a heparin infusion and has been charted targin and endone, which is providing inadequate pain relief.

 

1. Initial questions to ask over the phone

  • How does the patient score his pain out of ten?
  • Where is the pain?
  • What is helping with the pain?
  • What is the patient's medical history?
  • What other medications is the patient taking?

2. How do you assess the pain?

  • SOCRATES
  • Examine the patient
    • Current degree of distress

3. Features consistent with neuropathic pain?

  • History descriptors
    • Electric shock
    • Shooting
    • Freezing cold
    • Pins and needles
    • Radiating pain
  • Examination
    • Sensory changes, increased or decreased

4. What is allodynia?

  • Pain in response to a not normally painful stimulus

5. How do you treat neuropathic pain?

  • Multimodal and multidisciplinary approach
  • Pharmacological
    • Small doses of antidepressants, TCA, SSRI or SNRI = first line
      • If the pain is impacting sleep TCA are usually preferred, for example, Amitriptyline 5-10mg nocte, with dose increases every 3-5 days up to 25mg
      • If there is a mood component SNRI are preferred, for example, Duloxetine, 30mg mane, titrating the dose every week
    • Gabapentinoids = alternative first line
      • Opiods = third line, as tolerance and dependence become problematic non-pure mu agonists are preferred, for example, tramadol or palexia
  • Non-pharmacological
    • Physiotherapy, ensuring ongoing movement and mobility
    • TENS
    • Location specific interventions, for example, lumbar sympathectomy or spinal cord stimulation

6. When to ask for a chronic pain team consult?

  • If your initial plan does not adequately alleviate the pain, you should ensure to seek guidance as neuropathic pain is very distressing for patients

7. Prognosis

  • The longer the pain is present the greater the risk of not achieving a pain free state

Take home messages

  • First line management for neuropathic pain is low dose antidepressants or gabapentinoids
  • Do not try and treat neuropathic pain with escalating opioid therapy, however if using opioids, non-pure mu agonists are preferred and more effective than pure mu agonists

Resources

  • Acute pain management: A Practical Guide, Fourth Edition by Pamela E. Macintyre, Stephan A. Schug.

 

Useful resources

Pain consult guide

 

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Podcast

Diagnosis and management of Neuropathic Pain