nerve pain

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General Principles of Treating Neuropathic (Nerve) Pain

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General tenants:

I.  Don't be in a hurry to get out of pain!

The medications that most successfully reduce neuropathic pain in terms of reducing pain severity, the quality of pain relief and durability of relief ALL take time to work.  An expectation that they will work like commonly used pain relievers (opioid medications: such as vicodin, codeine, etc) will result in PROFOUND DISAPPOINTMENT and more importantly may cause you to prematurely put aside one of the few medications that can produce long-term profound pain relief.  In other words an expectation that they will work like other common pain relieving meds will "burn" (cause you to reject) a drug that might--if used differently with different expectations—have been very successful.  This is for several reasons:

1)   Unlike the opioid medications where you take a little and they help a little; take more and they help more, many of these "anti-neuropathic" medications appear to exhibit a threshold effect in any given individual.  In other words a patient might feel no relief at 25 mg, or 50 mg, and then at 75 mg suddenly start to feel relief and then at 150mg feel profound relief.  So your initial experience of the drug may not reflect your subsequent experience.  You might then ask why not just start the higher dose?

2.  When started at "effective" doses these drugs usually create side effects that can be largely avoided by slowly titrating up from a much lower dose and allowing your body to accommodate to the effects of the medication.  In other words drug X may make you very nauseated if started at 60 mg a day, but if started at 20 mg a day, and then each week increasing the dose by 20mg until you get to 60 mg then nausea is very rare.  So it is better to start at a low dose and work your way up.  It is generally very difficult to talk someone into re-trying a drug they are convinced makes them puke (or be dopey etc.) because of their experience from previously taking it at too high an initial dose.

3.  There is some evidence that even though these drugs may exert some effect immediately at any given dose, the degree of pain relief may really build substantially over the first few weeks of treatment.  No-one has a real good explanation for this, but we wave our hands and talk about things like "central sensitization".

4.  Unlike penicillin where you can just pick the right dose—with all of these anti-neuropathic medications doses have to be significantly tailored to the individual. I don't know what dose may be too much for one person and not enough for another.  Essentially you have to test a given dose in a given person and then slowly change the dose to see at any given dose the degree of side effects and the degree of pain relief.

So the mantra is START LOW and GO SLOW!!!

START LOW  (start at a dose that you are really confident won't create side effects—usually a dose too low to be effective)

GO SLOW! ( increase the dose by small increments every few days or each week so that you plan to reach your target dose in a month to two months)

But GO! ( when you start one of these medications don't just pick a low dose and leave it there or decide that it doesn't work just because it isn't having an effect at that low dose) these medications should generally be slowly titrated up until either:

      a)  You are getting significant pain relief or you are reaching a dose defined by the medical literature to include some risk of sudden significant hazard (e.g. an arrhythmia that might occur without you feeling this adverse effect coming on slowly)


      b)  You start reaching dose-limiting side effects (e.g. the medication is making you feel too sleepy or too nauseated).

II.   Only Change One Thing at a Time.

People in pain want to get out of pain right now and for that reason are tempted to try multiple things at the same time.   When you run into side effects you don't know which intervention is causing the side effect, and if it works you don't know what works.  Slowly learning what works and what doesn't; and why things don't work (e.g. lack of efficacy versus overwhelming side effects) is important to eventually achieving success.

III.  Nothing Ventured, Nothing Gained.

It is okay to not like taking medications, but with chronic pain if you don't change something –a medication or something else—then nothing will change. .  And if you are in you have to be committed.  Taking these meds one day and skipping them the next because of frustration etc. will generally make you feel really bad.  So decide to give them a real 6 week trial, or decide that you are not ready—but don't do the half-measures thing.  They don't work when used this way and you wind up mis-educating yourself that these medications don't work when in reality they are not working because of the way you are using them.


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