DEAR DOCTOR K:
I suffer from what my doctor calls “chronic neuropathic pain.” What are my treatment options?
There are two main types of pain. Nociceptive pain results from an injury to tissues outside your nervous system. Burns, sprains and broken bones are all examples of nociceptive pain. Tiny nerve fibers are always present in tissues. When the tissue gets injured, the nerve fibers detect it. The signal they send the brain is nociceptive pain. The signal says to the brain: “Do something to avoid further injury!”
Neuropathic (nerve) pain is the second type of pain. That’s the pain your doctor has diagnosed. It results from injury to or malfunction of the nerves themselves. This causes abnormal processing of pain signals and sensations. As a result, the nerve that was the mere messenger of pain now becomes a source of pain.
Neuropathic pain can result from diseases or conditions as varied as diabetes, shingles, multiple sclerosis, Parkinson’s disease, spinal cord injury or stroke. The pain may be felt as a burning or shooting pain, or you may have an unpleasant sensation of pins and needles. The pain may move out from one part of the body and spread to adjacent areas. It can be chronic and difficult to manage.
You have likely already tried conventional over-the-counter pain relievers such as acetaminophen (Tylenol) ibuprofen (Advil, Motrin) or naproxen (Aleve). These medicines work a lot better for nociceptive pain than for neuropathic (nerve) pain.
I think there is little evidence that prescription pain medicines — particularly the potent opioid medicines — are effective for neuropathic pain. Since they are addicting and can cause serious side effects, they should never be continued unless it is clear they are relieving suffering.
For neuropathic pain, other types of drugs (all requiring prescriptions) can be more effective than traditional pain medicines. Adding one of these following types of drugs won’t completely control your nerve pain, but it may help:
- ANTICONVULSANTS. These anti-seizure medications also help to blunt pain signals in the nerves. The most commonly used for nerve pain are gabapentin (Neurontin) and pregabalin (Lyrica). They take four to six weeks for the full effect to kick in.
- ANTIDEPRESSANTS. Certain types of antidepressants can also help to control nerve pain:
(a) Tricyclic antidepressants. These drugs have the strongest evidence backing their ability to manage nerve pain.
(b) Serotonin-norepinephrine reuptake inhibitors (SNRIs). These drugs are prescribed at lower doses for pain than they are for depression. SNRIs have fewer side effects than tricyclics, but they may be less effective in treating neuropathic pain.
(c) Selective serotonin reuptake inhibitors (SSRIs). These drugs are commonly prescribed for depression. Some doctors may try these for treating neuropathic pain, too. In my opinion, the evidence that they are effective for neuropathic pain is mixed.
When I was in medical school, we had few effective treatments for neuropathic pain. While we still need better treatments, we’ve made real progress.