Neuropathic Pain Article Featured on Cover of Practical Pain Management
I recently wrote an article about nerve pain for Practical Pain Management titled “Assessment and Treatment of Neuropathic Pain.” I just learned that they have chosen to feature the article on the cover of this month’s issue! Practical Pain Management is the most read journal for pain specialists and I am honored to have my article featured in such a big way. My co-author, Mark Wallace, is the chief of the Division of Pain Medicine at the University of California, San Diego. Although the paper is aimed at other pain specialist physicians, and is somewhat long and technical, I thought I’d take the opportunity to discuss the very common problem of neuropathic pain.
What is Neuropathic Pain?
Simply put, neuropathic pain refers to any sort of pain that originates from the nerves of your body. This is in contrast to types of pain like nociceptive pain, which is the pain you feel briefly when exposed to something painful (like the momentary pain from a flu shot), or inflammatory pain, which comes from soft tissue damage after an injury. In neuropathic pain, the pain source is the nerve itself.
Symptoms of Nerve Pain
Although people experience pain in different ways, neuropathic pain is often described as a burning or “pins and needles” sort of pain. Areas of the body can be hypersensitive to pain, and in some cases even light touch can trigger intense pain. In peripheral neuropathy, one common cause of neuropathic pain, the hands and feet are often the most affected (see the image from the Practical Pain Management article below). The pain can be associated with other nerve problems like numbness or weakness. Postherpetic neuralgia, another common type of nerve pain, occurs in the distribution of a prior shingles outbreak. In clinic, I use a focused neurological exam in combination with various diagnostic tools to determine the cause of pain. Even sciatica is a sort of neuropathic pain, typically originating from irritated nerve roots.
Treatment of Neuropathic Pain
When possible, the first step is to treat an underlying cause of neuropathic pain. For instance, if diabetes is causing a peripheral neuropathy, the most important thing for my patient is to get the diabetes under optimal control. However, it is not always possible to treat an underlying cause. In some cases, the nerve injury is irreversible.
In my article, I highlight the different levels of treatment for neuropathic pain. It is important to consider the lowest-risk interventions first, such as physical therapy, psychological therapies, and exercise. Nevertheless, many patients benefit from a more aggressive approach with medications. Although many people associate the idea of “pain medicine” with over-the-counter drugs like ibuprofen and Tylenol, or opioid drugs like hydrocodone, there are many different classes of medication that can be safer and more effective for pain when it comes from irritated or injured nerves. These include medications like gabapentin, which are considered anticonvulsants, and some drugs like tricyclics and SNRIs which were invented for depression but have since been discovered to be useful treatments for nerve pain. The FDA has also approved two types of topical medications which can be applied to the skin for some nerve pain: lidocaine, a numbing local anesthetic, and capsaicin, the active ingredient in chili peppers which paradoxically can reduce pain when applied regularly or in high concentration. I often order customized multidrug creams from compounding pharmacies as well. Finally, depending on the type of nerve pain, it may be possible to try an interventional procedure like a nerve block, epidural injection, or even spinal cord stimulator to treat tough cases. Such interventions depend on the exact diagnosis and are not always a good option.
What new therapies can we expect for nerve pain in coming years? There is some evidence for cannabis-related compounds, and some future drugs may come from that emerging neurochemistry. NGX426 is a new agent that showed promise in preliminary studies at UCSD. Botox, which is currently approved for migraines, seems to have some promise for nerve pain as well.