6. Pharmacological Management of Neuropathic Pain

Actionable Nuggets for SCI (3rd ed., 2016)

The Problem:Man with hand on wheelchair

It is estimated that neuropathic pain affects 40% to 75% of individuals with spinal cord injury (SCI). Neuropathic pain can result from nerve root damage, spinal cord damage or syringomyelia. Pharmacological management of pain in SCI must take into account a number of factors, such as: polypharmacy for other SCI-related complications; altered pharmacokinetics due to SCI; effect of pharmacological interventions on function and fatigue; effect of inadequately treated pain on functioning and quality of life.

Actionable Nugget

Use a step-wise evidence-based protocol for the management of neuropathic pain in SCI, and review pain management annually.

Evidence-based Best Practice:

Stepwise pharmacological management of neuropathic pain is as follows:

  • First-line agents –> gabapentinoids, tricyclic antidepressants, serotonin noradrenalin re-uptake inhibitors (SNRI’s)
  • Second-line agents –> controlled-release opioid analgesics, tramadol
  • Third-line agents –> cannabinoids
  • Fourth-line agents –> methadone, other anti-convulsants (eg., lamotrigine, lacostamide), tapentadol, botulinum toxin
  • Neuropathic pain has been shown to be generally poorly treated in the community, and many individuals with SCI experience pain that is refractory to pharmacological agents. Evidence is beginning to emerge for physical modalities, such as electrical and magnetic stimulation. For those with refractory pain, referral to a tertiary pain clinic may be advised, for multidimensional pain management including cognitive/psychological therapies and alternative/complementary modalities.

 Key Reference:

    Moulin, D. E., Boulanger, A., Clark, A. J., Clarke, H., Dao, T., Finley, G. A., … & Sessle, B. J. (2014). Pharmacological management of chronic neuropathic pain: revised consensus statement from the Canadian Pain Society. Pain Research and Management, 19(6), 328-335. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4273712/pdf/prm-19-328.pdf

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