How Can I Manage Neuropathic Pain?
Neuropathic pain is a complicated cross-traffic of nerve and muscle pathology, social dysfunction, mood alterations, and depression. When a patient fails to get relief, hopelessness amplifies the perception of pain. The treatment for neuropathic/chronic pain requires a multidisciplinary approach that includes medication, physical therapy, behavioral and psychological intervention, and surgical therapies that can include neurostimulators and implanted pumps for medication delivery into the spinal fluid.
Of all of these treatment modalities, the main three are medication, behavioral/psychological therapy, and physical therapy.
The line between chronic pain and neuropathic pain is often blurred, since neuropathic pain is a type of chronic pain. Opioid medication and other analgesics, a standard treatment for severe, unremitting pain, is often used in treating neuropathic pain, too. Anticonvulsants affect the nerve transmission of pain; anti-anxiety agents and antidepressants also have a role; and antispasmodics help when muscle spasm is involved. Since strong medication has an increasing potential for side effects, complications, and abuse, the usual protocol calls for a medication “pyramid” with multiple tiers of drugs to try, from the safest to the ones requiring the most scrutiny.
The types of drugs used in neuropathic pain include nonopioid analgesics (acetaminophen, NSAID), anticonvulsants (gabapentin, pregabalin), antidepressants, antispasmodics, and even medicinal marijuana.
Neuropathic pain, when initially treated with antidepressants, use the ones which inhibit the reuptake (keep levels higher) of neurotransmitters known to affect pain–serotonin and norepinephrine. (These are neurotransmitters found in the inhibitory pathway from the brain.)
Biofeedback and cognitive-behavioral therapy and psychological therapy are useful for both the physical pain and the psychological impact that augments it.
The goal of pain management is not to make one pain-free, as this is seldom accomplishable. Instead, the goal is to make a patient functional, either in spite of the pain or by mitigating its severity. One of the best approaches to restoring functionality is via physical therapy, which not only uses active and passive motion to reduce pain, but trains the patient how to alter lifestyle to keep the improvements in place.
Transcutaneous electrical nerve stimulators (TENS units) can send impulses to the spine to block the painful impulses. Spinal neurostimulation using implantable electrodes can do the same but target the painful area more specifically. Deep brain stimulation and other novel approaches are being investigated.
Besides implantable stimulators or pain pumps, interventional methods include injections of steroids and/or local anesthetic into the problem sites. Nerve ablation can effectively stop the pain transmission but can run the risk of affecting other nerve functions when the nerve has a mixed purpose of both sensory and motor roles.