Management of neuropathic pain (non-malignant) Medicines Initiation Protocol Introduction • Pain is one of the most common reasons that patients present to Primary Care • It is known that there are widespread changes within the nervous system that give rise to persistent pain. • According to the British Pain Society, one in seven people is thought to suffer from persistent pain and twenty percent of those report suffering for more than 20 years. People with pain consult their doctor up to five times more frequently than others, resulting in nearly 5 million GP appointments each year. • Poorly managed chronic pain can affect quality of life for sufferers and their carers, leading to helplessness, isolation, depression and family breakdown. Recommendations • This guidance is intended to guide management and recommendations are based on established practice throughout the UK and relevant NICE guidance. • Chronic pain is a bio-psychosocial problem. Chronicity of pain may cause complexity, both neuropathic and psychosocial. • It should be emphasised that medicines play only a minor part in managing persistent pain (30-50% reduction at best). Patient expectation should be managed at the outset of treatment. Any medication is offered on a trial basis, it will be withdrawn unless there is a good reason to continue due to the long term risks of dependency, memory problems, unsteadiness and weight gain. • Sleep is important in helping patient to manage their pain. • Maintaining fitness, pacing activities and a generally healthy lifestyle are important. Non- pharmacological methods of pain relief such as TENS, acupuncture, physical methods for the reduction of muscle spasm are equally important. • All patients with chronic pain should have psychosocial issues considered earlier rather than later ‘Yellow Flags’ • All patients should be screened for common mental health problems that may result from experiencing difficult to control pain. The following process diagram summarises the pathway to be followed when suspecting a pain problem with a neuropathic element. Further detail on each step in the pathway can be found later in the document. Eastbourne, Hailsham and Seaford CCG Hastings and Rother CCG Kirstie Ingram January 2015 Assessment of the pain - is there a neuropathic element? Consider current/previous medication - Consider use of Rule out any Red questionnaire/rating scales neuropathic pain responds poorly to Flags (Fig.1) conventional analgesia Working Diagnosis of Chronic Pain with Neuropathic Element Assess psychosocial element 'Yellow Flags' Pharmacological management of pain (Fig.2) Refer if present Offer initial treatment according to prescriber decision aid (Fig.3) Traffic light system - Green drugs should Provide patient information Appendix A normally be used first line Dose titration Review Refer if presence of red/yellow flags, symptoms unresponsive to treatment, patient does not want drug therapy or further advice required Assessment of the problem Neuropathic pain is very challenging to manage because of the heterogeneity of its aetiologies, symptoms and underlying mechanisms. There are many possible causes of neuropathic pain. Most common causes of neuropathic pain are diabetes, herpes zoster, trigeminal neuralgia and surgery e.g. post hernia repair. Intensive treatment of Diabetes Mellitus (including lipids, blood pressure and glycaemic control) may reduce the development and progression of diabetic painful peripheral neuropathy and should be considered as part of a multidisciplinary holistic approach to patient care. However, because many pain types can have a component of neuropathic (nerve) pain it is important to think about whether this is the case when assessing patients' pain. There are a Eastbourne, Hailsham and Seaford CCG Hastings and Rother CCG Kirstie Ingram January 2015 number of clues that can help with this, many of which depend on how the pain is felt and what character it has. There is often uncertainty regarding the nature and exact location of a lesion or health condition associated with neuropathic pain, particularly in non-specialist settings. Neuropathic pain can be intermittent or constant, and spontaneous or provoked. Typical descriptions of the pain include terms such as shooting, stabbing, like an electric shock, burning, tingling, tight, numb, prickling, itching and a sensation of pins and needles. Some of these symptoms and descriptors are drawn together in questionnaires that can be useful in assessing pain, such as the McGill Pain Questionnaire or a simpler questionnaire derived from it called the Short-Form McGill Pain Questionnaire. There are also several useful rating scales which can be helpful in making this assessment. In particular, the PainDETECT scale, DN4 (Douleur Neuropathique 4) and Leeds Assessment of Neuropathic Symptoms Scales (LANSS or s-LANSS). It is also very important to make an assessment of the effect the pain is having on the person’s lifestyle, daily activities (including sleep disturbance) and participation. Consider medication the patient is currently taking or has been tried already. Neuropathic pain often responds poorly to conventional analgesia. Rule out any red flags. Red flags are clinical indicators of possible serious underlying conditions requiring further medical intervention. Red flags were designed for use in acute low back pain, but the underlying concept can be applied more broadly in the search for serious underlying pathology in any pain presentation. Differential diagnosis Red Flags from patient history Red Flags from examination • Major trauma Possible fracture • Minor trauma in elderly or osteoporotic • Age < 20 or > 50 years old Possible tumour, infection or • History of cancer inflammation • Constitutional symptoms (fever, chills, weight loss) • Evidence of neurological deficit • Recent bacterial infection (in legs or perineum in the case • Intravenous drug use of low back pain) • Immunosuppression • Screening with blood tests and other investigations • Pain worsening at night or when supine • Undiagnosed chronic inflammatory cause • Severe or progressive sensory Possible significant neurological alteration or weakness deficit • Bladder or bowel dysfunction Figure 1. Red flags - clinical indicators of possible serious underlying conditions requiring further medical intervention Eastbourne, Hailsham and Seaford CCG Hastings and Rother CCG Kirstie Ingram January 2015 Assessment of psychosocial element Once a working diagnosis of chronic pain with neuropathic element has been established, assess the effect the pain is having on the person’s lifestyle, daily activities (including sleep disturbance) and participation (if not already undertaken) and screen for yellow flags (Figure 2.). Yellow Flags are psychosocial factors associated with unfavourable clinical outcomes and the transition to persistent pain and disability. They also flag other factors relating to perceptions about the relationship between work and health, which are associated with reduced ability to work and prolonged absence. If yellow flags are identified, consider discussing options with pain management services. Early intervention is associated with better outcomes and patients should be strongly encouraged to engage with support programmes (including pain rehabilitation). There is a lot of information and self-help resources that patients can access to support them to live with chronic pain http://www.nhs.uk/Livewell/Pain/Pages/Painhome.aspx http://chronicpainscotland.org/patients-area/living-well-with-chronic-pain/ These resources include information on Exercise and Activity, Dealing with Stress and relaxation, and Workplace issues/advice Coping strategies for pain management can also be found on this site www.paintoolkit.org Signposting to support services for patients with financial difficulties may also be helpful http://www.adviceguide.org.uk/england/debt_e.htm https://www.moneyadviceservice.org.uk/ en/tools/debt-advice-locator Attitudes and Beliefs • Pain is harmful or severely disabling • Expectation that passive treatment rather than active treatment may help • Feeling that ‘no-one believes the pain is real’ –may relate to previous encounters with healthcare professionals Emotions and • Fear-avoidance behaviour (avoiding activity due to fear of pain) Behaviour • Low mood and social withdrawal • Lack of job satisfaction Other psychosocial • Poor family relationships or history of abusive relationships factors • Financial concerns particularly related to ill-health or ongoing pain • Poor social support from colleagues • Company policy on sick leave • Threats to financial security (e.g. benefit changes) • Ongoing litigation related to persistent pain problem • Lack of contact with work Figure 2. Yellow flags – indicators of a psychosocial element Eastbourne, Hailsham and Seaford CCG Hastings and Rother CCG Kirstie Ingram January 2015 Offer pharmacological treatment Neuropathic pain not responding to simple analgesia and with symptoms such as sleep disturbances, depression and interference with normal daily activities should be treated according to the prescriber decision aid below (Figure 3). Offer a choice of amitriptyline, duloxetine or gabapentin as initial treatment. Treatment should be chosen based on individual patient factors and acquisition cost of the medicine (see Table 1 below). Pregabalin should usually be reserved for prescribing following discussion of options with a specialist. A prescribing decision aid has been devised to support this process (Figure