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Neuropathic pain

Short Text

The pharmacological management of neuropathic pain in adults in non-specialist settings

Introduction

This pathway covers the pharmacological management of neuropathic pain in adults in non-specialist settings.
Non-specialist settings are primary and secondary care services that do not provide specialist pain services. Non-specialist settings include general practice, general community care and hospital care.
Specialist pain services are those that provide comprehensive assessment and multi-modal management of all types of pain, including neuropathic pain.
A number of pharmacological treatments can be used to manage neuropathic pain outside of specialist pain management services. However, there is considerable variation in how treatment is initiated, the dosages used and the order in which drugs are introduced, whether therapeutic doses are achieved and whether there is correct sequencing of therapeutic classes. A further issue is that a number of commonly used treatments are unlicensed for treating neuropathic pain, which may limit their use. These factors may lead to inadequate pain control, with considerable morbidity.
Commonly used pharmacological treatments include antidepressants (tricyclic antidepressants, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors), antiepileptic (anticonvulsant) drugs, topical treatments and opioid analgesics. In addition to their potential benefits, all of these drug classes are associated with various adverse effects.
The pathway aims to improve the care of adults with neuropathic pain by making evidence-based recommendations on the pharmacological management of neuropathic pain outside of specialist pain management services. A further aim is to ensure that people who require specialist assessment and interventions are referred appropriately and in a timely fashion to a specialist pain management service and/or other condition specific services.
The pathway also includes NICE guidance on surgical procedures that may be among treatments offered in specialist settings.

Source guidance

The NICE guidance that was used to create the pathway.
Neuropathic pain – pharmacological management. NICE clinical guideline 173 (2013)
Percutaneous electrical nerve stimulation for refractory neuropathic pain. NICE interventional procedures guidance 450 (2013)

Quality standards

Quality statements

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Information about drug treatments for neuropathic pain

Information about surgery and procedures that may be used in specialist clinics

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

2 December 2013 Minor maintenance updates.

Supporting information

Glossary

A specialist service that provides treatment for the underlying health condition that is causing neuropathic pain. Examples include neurology, diabetology and oncology services.
The World Health Organization ICF (International Classification of Functioning, Disability and Health) (2001) defines participation as 'A person's involvement in a life situation'. It includes the following domains: learning and applying knowledge, general tasks and demands, mobility, self-care, domestic life, interpersonal interactions and relationships, major life areas, community, and social and civil life.
Non-specialist settings are primary and secondary care services that do not provide specialist pain services. Non-specialist settings include general practice, general community care and hospital care.
Specialist pain services are those that provide comprehensive assessment and multi-modal management of all types of pain, including neuropathic pain.
Specialist pain services are those that provide comprehensive assessment and multi-modal management of all types of pain, including neuropathic pain.
A condition-specific service is a specialist service that provides treatment for the underlying health condition that is causing neuropathic pain. Examples include neurology, diabetology and oncology services.

Person with neuropathic pain presents in a non-specialist setting

Person with neuropathic pain presents in a non-specialist setting

Key principles of care

Key principles of care

Key principles of care

When agreeing a treatment plan with the person, take into account their concerns and expectations, and discuss:
  • the severity of the pain, and its impact on lifestyle, daily activities (including sleep disturbance) and participation
  • the underlying cause of the pain and whether this condition has deteriorated
  • why a particular pharmacological treatment is being offered
  • the benefits and possible adverse effects of pharmacological treatments, taking into account any physical or psychological problems, and concurrent medications
  • the importance of dosage titration and the titration process, providing the person with individualised information and advice
  • coping strategies for pain and for possible adverse effects of treatment
  • non-pharmacological treatments, for example, physical and psychological therapies (which may be offered through a rehabilitation service) and surgery (which may be offered through specialist services).
For more information about involving people in decisions and supporting adherence, see the NICE guideline on medicines adherence.
Consider referring the person to a specialist pain service and/or a condition-specific service at any stage, including at initial presentation and at the regular clinical reviews, if:
  • they have severe pain or
  • their pain significantly limits their lifestyle, daily activities (including sleep disturbance) and participation or
  • their underlying health condition has deteriorated.
Continue existing treatments for people whose neuropathic pain is already effectively managed, taking into account the need for regular clinical reviews.
When introducing a new treatment, take into account any overlap with the old treatments to avoid deterioration in pain control.
After starting or changing a treatment, carry out an early clinical review of dosage titration, tolerability and adverse effects to assess the suitability of the chosen treatment.
Carry out regular clinical reviews to assess and monitor the effectiveness of the treatment. Each review should include an assessment of:
  • pain control
  • impact on lifestyle, daily activities (including sleep disturbance) and participation
  • physical and psychological wellbeing
  • adverse effects
  • continued need for treatment.
When withdrawing or switching treatment, taper the withdrawal regimen to take account of dosage and any discontinuation symptoms.

Source guidance

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Pharmacological treatment for all neuropathic pain except trigeminal neuralgia

Pharmacological treatment for all neuropathic pain except trigeminal neuralgia

Pharmacological treatment for all neuropathic pain except trigeminal neuralgia

Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain (except trigeminal neuralgia)At the time of publication (November 2013), amitriptyline did not have a UK marketing authorisation for this indication, duloxetine is licensed for diabetic peripheral neuropathic pain only, and gabapentin is licensed for peripheral neuropathic pain only, so use for other conditions would be off-label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the Good practice in prescribing and managing medicines and devices (2013) guidance for doctors for further information..
If the initial treatment is not effective or is not tolerated, offer one of the remaining 3 drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated.
Consider tramadol only if acute rescue therapy is needed (see Treatments that should not be used about long-term use).
Consider capsaicin creamAt the time of publication (November 2013), capsaicin cream (Axsain) had a UK marketing authorisation for post-herpetic neuralgia and painful diabetic peripheral polyneuropathy, so use for other conditions would be off-label. The summary of product characteristics states that this should only be used for painful diabetic peripheral polyneuropathy 'under the direct supervision of a hospital consultant who has access to specialist resources'. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the Good practice in prescribing and managing medicines and devices (2013) guidance for doctors for further information. for people with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments.

Source guidance

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Pharmacological treatment for trigeminal neuralgia

Pharmacological treatment for trigeminal neuralgia

Pharmacological treatment for trigeminal neuralgia

Offer carbamazepine as initial treatment for trigeminal neuralgia.
If initial treatment with carbamazepine is not effective, is not tolerated or is contraindicated, consider seeking expert advice from a specialist and consider early referral to a specialist pain service or a condition-specific service.

Source guidance

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Treatments that should not be used

Treatments that should not be used

Treatments that should not be used

Do not start the following to treat neuropathic pain in non-specialist settings, unless advised by a specialist to do so:

Source guidance

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Non-pharmacological treatments in a specialist setting

Non-pharmacological treatments in a specialist setting

Non-pharmacological treatments in a specialist setting

NICE has issued guidance on the following procedures, which may be among treatments offered in a specialist pain service or a condition-specific service.

Spinal cord stimulation for chronic pain of neuropathic or ischaemic origin

Spinal cord stimulation is recommended as a treatment option for adults with chronic pain of neuropathic origin who:
  • continue to experience chronic pain (measuring at least 50 mm on a 0–100 mm visual analogue scale) for at least 6 months despite appropriate conventional medical management, and
  • who have had a successful trial of stimulation as part of the assessment specified below.
Spinal cord stimulation is not recommended as a treatment option for adults with chronic pain of ischaemic origin except in the context of research as part of a clinical trial. Such research should be designed to generate robust evidence about the benefits of spinal cord stimulation (including pain relief, functional outcomes and quality of life) compared with standard care.
Spinal cord stimulation should be provided only after an assessment by a multidisciplinary team experienced in chronic pain assessment and management of people with spinal cord stimulation devices, including experience in the provision of ongoing monitoring and support of the person assessed.
When assessing the severity of pain and the trial of stimulation, the multidisciplinary team should be aware of the need to ensure equality of access to treatment with spinal cord stimulation. Tests to assess pain and response to spinal cord stimulation should take into account a person's disabilities (such as physical or sensory disabilities), or linguistic or other communication difficulties, and may need to be adapted.
If different spinal cord stimulation systems are considered to be equally suitable for a person, the least costly should be used. Assessment of cost should take into account acquisition costs, the anticipated longevity of the system, the stimulation requirements of the person with chronic pain and the support package offered.
People who are currently using spinal cord stimulation for the treatment of chronic pain of ischaemic origin should have the option to continue treatment until they and their clinicians consider it appropriate to stop.
These recommendations are from spinal cord stimulation for chronic pain of neuropathic or ischaemic origin (NICE technology appraisal guidance 159).
NICE has written information for the public explaining its guidance on spinal cord stimulation for chronic pain of neuropathic or ischaemic origin.

Interventional procedures guidance

NICE has published interventional procedures guidance on the following procedures:

Source guidance

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Paths in this pathway

Pathway created: November 2013 Last updated: December 2013

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