Neuropathic Pain—We Can, and Should do Better!

In terms of diagnosis and treatment of neuropathic pain, we have a long way to go.  Many patients have a component of neuropathic pain to their overall pain experience that is not recognized by those taking care of them. And then often when it is recognized, it’s not treated adequately. An example would be the person who comes to see you for something else, and they mention that their feet burn at night and you discover they have diabetes. So, now you treat their diabetes and that can be very good for their overall health. But in terms of where we are with treating neuropathic pain, we don’t have great agents, and we don’t use them very well.

I think that the treatment guidelines for neuropathic pain are helpful because they tell you the evidence behind the treatments we have. What they don’t do is help select which patient to give which drug to and in which order. And they also don’t consider other things that we know are important to the patient’s quality of life like sleep, regular exercise, diet and general health; their depression, anxiety and mental health situation. They don’t really look at treatments that aren’t pharmacologic treatment. But if you’re going to select a medication for treating neuropathic pain, it makes sense to stick with things that are in the guidelines. The French have done a better job of disseminating their neuropathic pain guidelines such that they get read by folks. And so primary care providers in France do a fantastic job of identifying neuropathic pain almost 90% or 87% of the time. Then once they identify neuropathic pain, they select a first line agent 90% of the time. In the US, the evidence suggests that’s not the case. That includes a study from Bob Dworkin looking at treatment of post-herpetic neuralgia in the community showing that only 25% of patients got a first line drug. There are surveys of patients with neuropathic pain that found that many are on medications that don’t have any evidence of working for neuropathic pain. So, we have a way to go to be more like the French. Our guidelines are not well utilized and, I don’t think they’re placed where primary care physicians see them. If I was a primary care physician I would never have seen the neuropathic pain special interest group treatment guidelines for neuropathic pain. I would not have stumbled across that because I don’t read Lancet and Neurology. So, we need to make sure that this kind of data get presented in venues where primary care are actually going to see it. That’s one of the values of PAINWeek; this kind of information is provided to primary care providers and comes to those in the trenches who are actually taking care of patients.