A Comprehensive Algorithm for Management of Neuropathic Pain

Daniel Bates; B Carsten Schultheis; Michael C Hanes; Suneil M Jolly; Krishnan V Chakravarthy; Timothy R Deer; Robert M Levy; Corey W Hunter

doi:10.1093/pm/pnz075

A Comprehensive Algorithm for Management of Neuropathic Pain

Pain Med. 2019 Jun 1;20(Suppl 1):S2-S12. doi: 10.1093/pm/pnz075.

Authors

Daniel Bates¹, B Carsten Schultheis², Michael C Hanes³, Suneil M Jolly^{4

5}, Krishnan V Chakravarthy^{6

7}, Timothy R Deer⁸, Robert M Levy⁹, Corey W Hunter¹⁰

Affiliations

¹ Metro Pain Group, Victoria, Australia.
² Muskuloskelettales Zentrum - Interventionelle Schmerztherapie, Krankenhaus Neuwerk "Maria von den Aposteln," Mönchengladbach, Germany.
³ Jax Spine & Pain Centers, Jacksonville, Florida.
⁴ Louisiana Pain Specialists, New Orleans, Louisiana.
⁵ New Orleans East Hospital, New Orleans, Louisiana.
⁶ Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, La Jolla, California.
⁷ Veterans Administration San Diego Healthcare System, San Diego, California.
⁸ The Spine and Nerve Center of the Virginias, Charleston, West Virginia.
⁹ Institute for Neuromodulation, Boca Raton, Florida.
¹⁰ Ainsworth Institute of Pain Management, New York, New York, USA.

Abstract

Background: The objective of this review was to merge current treatment guidelines and best practice recommendations for management of neuropathic pain into a comprehensive algorithm for primary physicians. The algorithm covers assessment, multidisciplinary conservative care, nonopioid pharmacological management, interventional therapies, neurostimulation, low-dose opioid treatment, and targeted drug delivery therapy.

Methods: Available literature was identified through a search of the US National Library of Medicine's Medline database, PubMed.gov. References from identified published articles also were reviewed for relevant citations.

Results: The algorithm provides a comprehensive treatment pathway from assessment to the provision of first- through sixth-line therapies for primary care physicians. Clear indicators for progression of therapy from firstline to sixth-line are provided. Multidisciplinary conservative care and nonopioid medications (tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, gabapentanoids, topicals, and transdermal substances) are recommended as firstline therapy; combination therapy (firstline medications) and tramadol and tapentadol are recommended as secondline; serotonin-specific reuptake inhibitors/anticonvulsants/NMDA antagonists and interventional therapies as third-line; neurostimulation as a fourth-line treatment; low-dose opioids (no greater than 90 morphine equivalent units) are fifth-line; and finally, targeted drug delivery is the last-line therapy for patients with refractory pain.

Conclusions: The presented treatment algorithm provides clear-cut tools for the assessment and treatment of neuropathic pain based on international guidelines, published data, and best practice recommendations. It defines the benefits and limitations of the current treatments at our disposal. Additionally, it provides an easy-to-follow visual guide of the recommended steps in the algorithm for primary care and family practitioners to utilize.

Keywords: Neuromodulation; Neuropathic Pain; Pharmacological Treatment; Spinal Cord Stimulation; Targeted Drug Delivery.

Publication types

Research Support, Non-U.S. Gov't
Review

MeSH terms

Algorithms*
Humans
Neuralgia / therapy*
Pain Management / methods*