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June 2004, Volume 34 Number 6 , p 17 - 17





  • First line of defense

  • Second line of defense


    QUESTION: My patient has chronic peripheral neuropathic pain. Opioids don't work as well as he and I had hoped. What other medications are appropriate for this type of pain?

    ANSWER: Peripheral neuropathic pain can be one of the most difficult types of pain to manage. Only about one-third of patients achieve relief from around-the-clock dosing of opioid analgesics (with rescue doses for breakthrough pain).

    New evidence-based guidelines from the Fourth International Conference on the Mechanisms and Treatment of Neuropathic Pain recommend opioid analgesics, tricyclic antidepressants, gabapentin, and the 5% lidocaine patch as the first-line medications for chronic neuropathic pain. The guidelines also recommend developing preventive interventions for patients at risk for chronic neuropathic pain, including those undergoing breast cancer surgery and patients with herpes zoster or diabetes.

    Despite research, the origins of peripheral neuropathic pain are poorly understood. It may be caused by drug toxicity (for example, from chemotherapy), a metabolic disorder such as diabetes, or alcohol abuse, but it can also be idiopathic. Patients may describe their pain as continuous, deep, burning, aching, sudden, electrical shocks, sharp, stabbing, pins and needles, or shooting; they may also describe abnormal skin sensitivity (allodynia).

    Pain typically starts in the toes and progresses up the calves in both legs symmetrically; when pain reaches the knees, symptoms may begin in the fingers and move up the arms. The pain, which usually is disproportionate to physical findings, tends to be worse in the evenings and may be worse in the arms than in the legs.

    Pain may be accompanied by inflammation, hypersensitive skin, and temperature and circulatory changes. Besides the nervous system, nociceptive (musculoskeletal ...

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