Today's very useful post from neuropathy.org (see link below) is a series of commonly asked questions posed to Dr Hunter, followed by his answers. It may be that your own doctor will give slightly different responses to these questions, depending on either the sort of, or cause of your neuropathic problems but in general, most doctors would agree with Dr. Hunter's answers and in that respect this article can be seen as being helpful to the vast majority of neuropathy patients. Definitely worth reading, even for experienced neuropathy patients.
By Corey W. Hunter, M.D.
Addressing questions—even when there may be no clear cut answers—is a big part of what I do every day to help people living with chronic pain. Many patients I work with also battle neuropathic pain: some newly diagnosed, and others barely living through their pain. I realized recently that there is a theme to the questions I hear most often from my patients, and I hope that in sharing my responses to them, I can help you better understand your neuropathic pain and work with your health care provider to improve your life with neuropathic pain:
1. Why does it feel like my skin is burning? Numb? Pins and needles? What is causing me to have these symptoms?
Typically, a healthy nerve will only send a signal when it is stimulated, e.g., a nerve in the hand that senses temperature will stay quiet until the hand gets near the flame on the stove. However, an injured nerve is like a broken telephone that rings when no one is calling (burning) and is unable to get a dial tone when you need to make a call (numbness). Even when it has nothing of importance to say to the brain, the nerves will send a message and a confused message at that. The “confused” message can be interpreted by the brain as pain or strange sensations like “pins and needles.”
Over time, the spinal cord can become accustomed to getting bombarded by a nerve that never seems to turn off and makes adjustments to account for it. So, even once the nerve manages to stop firing, the spinal cord has become so used to sending that signal that it will take over and keep doing it on its own.
2. Why are my usual pain relievers--acetaminophen (or Tylenol), ibubrofen (or Motrin), or even the acetaminophen and oxycodone combination (or Percocet)--not working?
In very simple terms, there are two basic types of pain: nocioceptive (pain that can usually be pinpointed to an actual event, e.g., pain resulting from a broken arm) and neuropathic (pain that is vague and nondescript in nature, e.g., burning pain in the feet resulting from uncontrolled/too high blood sugars for too long causing injury to the nerves in the feet). The former is from an injury to a part of the body and the nerves in your arms or legs tell the brain that something was hurt and we feel pain. The latter is an injury to the nerve itself. Medications such as acetaminophen (or Tylenol), ibubrofen (or Motrin), and the acetaminophen and oxycodone combination (or Percocet) are effective in treating nocioceptive pain. They can decrease the inflammation at the injury which may mean the nerve now has less to tell the brain about the injury. They can also dull the pain message being sent altogether. However, when the pain itself is coming from an injury to the actual nerve, the effect will be limited. That is where neuropathic pain medications become important because they act on the nervous system directly.
3. What kind of tests can you order to see what is happening?
Neuropathic pain can be the result of an injury to a nerve or the nervous system which interferes with its function. MRIs are a good test to evaluate the body for structural abnormalities, but it tells you nothing about function. It is a still picture taken in a virtually motionless individual.
It is estimated that nearly ¾ of Americans have abnormalities which could be seen on an MRI but have no pain. On the flip side, there are many patients I have treated with no findings on the MRI which are consistent with their symptoms. This perhaps suggests it does not tell the whole story. The importance of an MRI should not be overlooked in diagnosing things like a bulging disc or soft tissue injury, but one should view it as more of a “guide” when it comes to neuropathy rather than a map.
A good test to evaluate the function and integrity of the nervous system is a nerve conduction study (NCV)/ electromyography (EMG). The NCV tests how fast a nerve can send a signal and how much of that signal is getting through. The EMG tests the interaction of those nerves with the muscles which gives the doctor an idea of whether the nerves are healthy.
4. Are there any medications I can take for this? How much relief can I expect?
Most patients who suffer from neuropathic pain will tell that traditional pain relievers tend to be ineffective. Medications such as acetaminophen and oxycodone combination (or Percocet) and acetaminophen and hydrocodone combination (or Vicodin) only “take the edge off,” but the burning and/or painful numbness seems to always be present, no matter how much they take. It is for this reason that opioids should not be considered as a first-line treatment option. Medications such as anti-depressants (e.g., duloxetine) and anticonvulsants (e.g., gabapentin and pregabalin) have been the mainstay for the treatment of neuropathic pain for some time now.
Tizanidine (or Zanaflex) is another medication which has been used fairly frequently for neuropathy. It is a muscle relaxer which has been used to treat spasticity in patients with cerebral palsy and is effective in treating neuropathy with small doses taken once daily. Methadone is also a particularly good medication as it not only acts as a powerful pain reliever but has been shown to be quite effective for neuropathic pain. An older medication called ketamine has come back into relevance as physicians have found it to be extremely effective for neuropathy. It can be used topically when added as the active ingredient in a cream or infused intravenously in a hospital setting under the supervision of your doctor.
The amount of relief varies from one patient to the next and it is nearly impossible to predict the degree of success one should expect. Many of the medications mentioned will need to be titrated to an effective dose which means your doctor will need to start with a smaller amount and slowly increase it over time. Others simply need time to build up in your body. Hence it is important to ask your doctor to help you understand what to expect with the medication(s) being prescribed: dosing, side effects, degree of relief, improvement in quality life and physical function…
5. My last doctor requested drug tests every time I saw him and he also asked me to bring my medications along so we could track how much I have left. Neuropathic pain is challenging enough, and then I have to deal with the stigma of being treated like an addict. Do you have any suggestions?
Presently, opioids are a very controversial topic and with that comes increased scrutiny and procedure. No one sets out to become addicted to prescription pain relievers, but the potential for dependency is always a concern. Because of this, strict monitoring should be in place for any patient on opioids to make sure they are being used appropriately and as directed – this includes the doctor or his/her staff counting the pills and even asking for a urine sample.
While they should not be considered a “first-line” therapy for neuropathic pain, opioids are commonly used by many physicians first simply because he or she may not know the most effective way to treat it. Therefore, you would not be incorrect in asking for an alternative therapy, even if the request is simply due to the perceived stigma and hassle that can accompany opioid use.
6. What types of treatments are there if the medications do not work? How much relief can I expect? Are there treatments that don’t involve medications or surgeries that I could try?
Physical therapy (PT) typically is prescribed at the very beginning or along with neuropathic pain medication. In cases where patients present as having failed medication and PT has not yet been provided, PT can still be tried. The prescription should include therapies that aim to decrease the intensity of the pain (i.e. contrast baths) and increase the function of the extremity (i.e. range of motion and strengthening).
If conservative measures fail, a skilled interventional pain physician may offer a plan that includes injections like a sympathetic or stellate ganglion block. In basic language, the doctor will attempt to deliver medication to the relay centers for the patient’s pain to slow down or even turn off the pathway. Other injections may be directed at the nerves themselves that are believed to be responsible for transmitting the pain. There are a variety of procedures which can offer relief which are all minimally invasive in nature.
Finally, there are implantable devices like spinal cord stimulators (SCS) and intrathecal pumps (ITP). Many physicians describe an SCS as “a pacemaker for the spinal cord.” There is a battery that is implanted just under the skin with a small, flexible lead that goes into the spine and essentially interferes with the cord’s ability to transmit pain. An ITP involves a reservoir placed right under the skin instead of a battery and a tube rather than a lead. In the reservoir, the doctor can place any pain medications or cocktail of medications he or she thinks will be effective. The advantage of the ITP is because the tube is placed right on the cord, less is needed.
7. Will this ever get better? Will the pain go away?
The chances of improvement depend on the extent of the injury to the nerve. If the injury is mild and the cells that support the nerve are left intact – the neuropathy should improve as the nerve heals. Many times the nerve is injured by a something that can be treated or reversed, i.e. a compressed or pinched nerve, chemotherapy or exposure to a toxic chemical. In these cases, whatever is the culprit can simply be removed from the equation and allow the nerve to heal. However, if the injuring agent is still present, it is harder for the nerve to heal. In fact, if the nerve stays injured for too long, the damage can be irreversible. The most important thing to keep in mind is the sooner a neuropathy is treated, the better the chances to have a good recovery.
8. Will this get worse? What should I expect five or ten years from now?
Neuropathic pain left untreated will undoubtedly get worse. The longer it is left untreated, the harder it is to get it to a manageable level even once the appropriate plan has been implemented. Unfortunately, even some patients who are under the care of a skill pain physician from the start will get worse. There is no way to predict who these patients will be or why so many others were successfully managed with the same therapies while others fail. As with any field in medicine, there are always exceptions to the rule. Compared to other specialties, pain medicine is relatively new and there is much we are still learning. With that, there are always new treatments being discovered.
9. Do a lot of your patients use multiple therapies for relief for their neuropathic pain? E.g., prescription medications, acupuncture, and physical therapy?
Treating pain should be thought of like climbing stairs. The first step should include the most basic therapy, like PT, and an over-the-counter pain reliever. As more care is needed, we climb to the next step. With each successive step, the more we add. By the third step, a patient may need to be on two different neuropathic pain medications, PT, and be scheduled for an injection. Treatments like acupuncture are not unusual to incorporate early on, as well. We call this a “multidisciplinary approach.” The idea is to not assume there is simply one main contributor to the pain and subsequently place all the focus on that. By spreading out the focus, the patient benefits from the idea of “casting a large net” and seeing which treatment works best, not to mention saving time early on.
Corey W. Hunter is a pain management specialist working at the New York Pain Management Group and is a member of The Neuropathy Association’s Neuropathic Pain Management Medical Advisory Council.
http://www.neuropathy.org/site/News2?page=NewsArticle&id=8259
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