Neuropathic Pain: Incorporating New Consensus Guidelines into the Reality of Clinical Practice
Highlights from a Roundtable Symposium
Activity Date: July 2004  — Activity Info: Volume 4, (7B)
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Expanding The Current Management Of Neuropathic Pain
Peter S. Staats, MD*

Sir William Osler was quoted as saying, "He who knows syphilis knows medicine." Today's analogy might be "Whomever knows pain knows medicine."

The years 2000 to 2010 mark the Decade of Pain Control and Research, as mandated by the US Congress. This effort has several important initiatives including the National Pain Care Policy Act of 2003, increased funding for research into the causes and treatment of pain, and public awareness programs.1 We hope that this effort will do for pain what Ronald Reagan and Charlton Heston have done for Alzheimer's disease, namely increasing awareness of the disease and therefore improving understanding of the pain patients experience.

Another important initiative of the Decade of Pain Control and Research is to increase professional awareness of the prevalence, causes, and treatment of pain. We see many statistics showing that pain is the most common reason for physician office visits and that at least 1 of every 5 Americans is affected by chronic pain.2 Yet, this basic human sensory experience can be the source of shame as well as personal and professional disability with sometimes drastic psychological, social, and financial repercussions. In most cases, chronic pain never fully remits and is often under- or untreated. Thus, the continued complaints of pain can elicit anger and resentment by friends, family, and coworkers, resulting in shame by the afflicted. Pain is not a disease that can be seen or even visually measured.  Much like Alzheimer's disease, there remain many unanswered questions and outright ignorance of the pain experience, leading to the anger and resentment of those not experiencing a chronic, lifelong condition.

Neuropathic pain—ie, pain caused by disease or dysfunction of the nervous system—is perhaps one of the most frustrating disorders to treat, for both the patient and the healthcare provider, including pain specialists. The diagnosis is not always obvious, the treatment algorithms heretofore nonexistent and not widely known, and the treatments themselves are often only partially able to remit the pain.

As with so many diseases—chronic and acute—primary care providers (ie, physicians, nurses, and pharmacists) are the "first face" of medicine for the patient. With a seemingly ambiguous condition such as neuropathic pain (ie, pain with no associated or resulting tissue damage), many primary care practitioners feel unable to treat pain patients. Neuropathic pain is the perfect example of why the Decade of Pain Control and Research is so important.

In November 2003, an August panel of pain specialists published the first set of guidelines for neurologists on treating neuropathic pain.3 The guidelines provide a direct path for choosing first-line therapies for neuropathic pain based on an extensive review of the literature, in line with our current drive toward evidence-based medicine. A reprint of these guidelines is included in this issue of Advanced Studies in Medicine.

Yet, for the primary care provider, how do these guidelines fit in to their practice, for the first encounter with a patient not yet diagnosed with neuropathic pain? To answer these needs, we convened our own panel of pain specialists from neurology, anesthesiology, primary care, nursing, and pharmacy. We discussed and debated the ways in which the guidelines for neurologists could be transformed and applied to everyday primary care clinical practice, where neuropathic pain patients are most often seen. Importantly, a member of our panel, Dr Charles Argoff, was one of the coauthors of the neuropathic pain guidelines.

The result of our discussions is a comprehensive resource to provide practical information on diagnosis, treatment, and long-term management of neuropathic pain in primary care. Most neuropathic pain patients can be effectively treated and managed in a primary care setting, if the providers have the appropriate tools. Our recommendations, also published in this issue of Advanced Studies in Medicine, are meant to complement the neurology guidelines, by addressing not only evidence-based medicine but also the wealth of our panel members' clinical experience on the realities of treating and managing neuropathic pain.

Of note, we review the 5 recommended first-line therapies, but also offer our own recommendations on second-line approaches because, as is all too often the case in medicine, one algorithm does not fit all patients. We spend a longer amount of time discussing opioids than the other 4 first-line drugs, not to discourage or encourage their use. Rather, our intent is to provide an in-depth, realistic discussion and necessary information to dispel myths on opioid use, so primary care practitioners can confidently prescribe them for appropriate patients.

In the end, there remain only a few important principles for neuropathic pain management: most medications by themselves will not provide complete pain relief (polypharmacy is common), the definition of "treatment success" must be redefined by both the healthcare practitioner and the patient, and the role of the healthcare provider is to not only provide clinical expertise but also instill hope in the patient such that all clinical encounters (as discussed in our recommendations) are "psychotherapeutic."

1. The American Pain Society Web site. Available at: Accessed May 9, 2004.
2. Nelson R. Decade of pain control and research gets into gear in USA. Lancet. 2003;362(9390):1129.
3. Dworkin RH, Backonja M, Rowbotham MC, et al. Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Arch Neurol. 2003; 60(11):1524-1534.

*Pain Physician, Metzger Pain Management, Shrewsbury, New Jersey; Adjunct Associate Professor, Department of Anesthesiology and Critical Care Medicine and Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Address correspondence to: Peter S. Staats, MD, Metzger Pain Management, 160 Avenue-at-the-Commons, Shrewsbury, NJ 07702. E-mail:

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