Ep. 17 Neuropathic Pain Algorithm
Dan and Juz cover the neuropathic pain algorithm, taking you through first through fourth line treatment options from most to least conservative. They cover trialing and combining various medications including opioids, topicals for focal areas of pain, and various interventional options all the way up to neuromodulation (peripheral or spinal cord stimulators), and pain pumps.
This episode helps a PCP or other physician have a guide to more efficiently work through treatments for neuropathic pain, and patients better understand their options so they can more effectively advocate for themselves. Visit the episode page at the website below for a link to download the paper with the algorithm.
Introduction
In this episode of "It's not in your head," Dr. Dan Bates and Justine Feitelson (Dan and Juz) delve into the complex world of neuropathic pain, building upon their previous discussions on Number Needed to Treat (NNT) and central sensitization. They present a neuropathic pain algorithm designed to guide primary care physicians (PCPs) through a standardized approach to diagnosis and treatment
Context and Purpose
Dr. Dan Bates developed this algorithm out of frustration with the overreliance on medication and the lack of comprehensive care for neuropathic pain patients. The algorithm aims to:
Provide PCPs with a roadmap for patient care
Incorporate guidelines and conservative approaches
Address the issue of limited access to treatment options
Offer a starting point for treatment based on individual patient history
Current Challenges in Neuropathic Pain Management
Lack of consensus in diagnosis and treatment
Need for standardization, especially for complex pathologies
Long delays in diagnosis for conditions like Complex Regional Pain Syndrome (CRPS)
Insufficient guidelines for post-intervention care
Diagnostic Approach
Patient History and Examination
Recognize the inherent unreliability of patient histories
Focus on identifying pain drivers and amplifiers
Assess the level of sensitization and mood
Determine appropriate tests and further investigations
Quantification and Definition
Gather information to define pain characteristics
Evaluate the extent of central sensitization
Consider the impact of sleep, fatigue, and mood on treatment targets
Treatment Algorithm
First-Line Treatments
Multidisciplinary care (MARS - Movement, Analgesia, Rehabilitation, Self-management)
Address pain amplifiers and co-existing conditions
Focus on pain acceptance and catastrophizing
Implement pain science education
Pharmacological Interventions
First-line Medications
Consider side effects and their potential to amplify pain
Regularly re-evaluate medication efficacy
Aim for long-term symptom improvement without compromising future treatment options
Second-line Medications
Explore combination therapy
Consider topical treatments for localized pain
Discuss ketamine therapy options and limitations
Interventional Treatments
Epidural injections (common in CRPS)
Pulse radiofrequency for nerve injury-related CRPS
Sympathetic blocks (short-term relief for CRPS)
Spinal cord stimulators (with trial periods)
Opioid Considerations
Understand the potential for opioid-induced hyperalgesia
Recognize opioids as a short-term solution with long-term consequences
Be aware of the impact on patient autonomy and agency
Importance of Holistic Care
Implement MARS principles throughout treatment
Address lifestyle factors and eliminate other variables/contributors
Provide ongoing support and individualized care plans
Emphasize the connection between treatment and patient goals
Click below to freely download the Neuropathic Pain Algorithm.