Diagnosis and management of neuropathic pain

Diagnosis and management of neuropathic pain

Aug 29, 2018 0
anaesthetics,General medicine,neurology,onthepods,psychiatry

James talks to Dr Jane Standen about the diagnosis and management of neuropathic pain.

Summary Writer:  Claudia Hurwitz

Script Writer: Dan Carayannis

Editor:  Jane Standen

Interviewee:  Jane Standen

About Dr Jane Standen

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.

Diagnosis and management of neuropathic pain

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

Introduction

Neuropathic pain refers to pain in association with a lesion or disease affecting 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.

  • 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?
  • SOCRATES
  • Examine the patient
    • Current degree of distress
  • History descriptors
    • Electric shock
    • Shooting
    • Freezing cold
    • Pins and needles
    • Radiating pain
  • Examination
    • Sensory changes, increased or decreased
  • Pain in response to a not normally painful stimulus
  • 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
  • If your initial plan does not adequately alleviate the pain, you should ensure to seek guidance as neuropathic pain is very distressing for patients
  • The longer the pain is present the greater the risk of not achieving a pain free state
  • 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
  • Acute pain management: A Practical Guide, Fourth Edition by Pamela E. Macintyre, Stephan A. Schug.

Useful resources

Related Podcasts

Tags: #allodynia,#Anaesthetics,#chronic pain,#junior doctors,#neuropathic pain,#Opioid,#pain management,#pain relief,#somatosensory nervous system,#tipsforinterns,#tipsfornewdocs

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