Download Borders Neuropathic Pain Guidelines – Guidance

Borders Neuropathic Pain Guidelines – Guidance Notes
These guidance notes should be read in conjunction with the Borders Neuropathic Pain
Pathway.
Clinical examples of neuropathic pain include diabetic neuropathy, post-herpetic
neuralgia, trigeminal neuralgia, HIV- related, chemotherapy or radiation- induced, nerve
root pain.
However nociceptive and neuropathic pain can co-exist, so please use these guidelines in
conjunction with World Health Organisation analgesia ladder.
Some analgesics can be useful to treat both types of pain, e.g. tricyclics, opioids,
including tramadol.
The importance of identifying the underlying cause of neuropathic pain cannot be
overemphasised. This may require further assessment, investigation and onward referral to
the appropriate speciality, prior to referral to the chronic pain service. The neuropathic
pain pathway can be implemented whilst other specialty input is awaited.
Prior to starting these drugs, it is well worth investing the time explaining to the patient the
rationale and practicalities of taking these drugs, as many of these drug “trials” fail due to
patients not understanding what to expect, why or how to take their medication
- nonconventional analgesics are used but they are not taken on an “as required” basis
like many conventional analgesics – they need to be taken regularly to work ie. every
day
- drugs tend to be indicated for other conditions eg. depression and epilepsy
- many potential side effects (information leaflets are available on chronic pain website)
- try to “start low and go slow” with upward titration to minimise side effects, following
the attached neuropathic pain pathway
- some tolerance to side effects seems to develop
- side effects tend to be experienced before benefits are seen
- approx 4-8 weeks at intended target dose of each drug before can decide if effective
or not
- drug “trial” may be ineffective, may need to consider trying other agents until best
agent (or best combination of drugs) for that individual is found (some pain does not
respond to any of these drugs)
- discussion about fitness to drive is advised for medications which are sedative or may
interfere with motor skills ie. Tricyclics, Gabapentin, Pregabalin
 Tricyclic Antidepressants (Amitriptyline/Imipramine/Nortriptyline)
Usual initial dose 10mg nocte, increasing in 10mg weekly increments up to 75mg nocte if
tolerated. Amitriptyline tends to be more sedating than Imipramine or Nortriptyline, though
night time sedation may be useful in some patients. Contraindicated in arrhythmias,
recovery after MI, in manic phase of bipolar disorder. Avoid Imipramine in pregnancy, see
BNF for tricyclic usage in preganacy. Note – many possible side effects and contraindications to tricyclic agents, see BNF. N.B. Exercise particular caution if a patient is
already receiving another anti-depressant for clinical depression as there is increased risk
of shared side-effects.
 Gabapentin
Suggested titration regime is available in the Gabapentin information leaflet on the chronic
pain website. If very concerned about sedation in particular, 100mg capsules are also
available for slower titration. Target dose is 600mg TDS. Note - dose reduction required in
renal impairment, watch for sedation, avoid abrupt withdrawal (withdraw over a minimum
of one week).
 Pregabalin
This can be initiated by GPs as a third line option. Suggested titration regime is available in
the Pregabalin information leaflet on the chronic pain website. Slower titration may suit
some patients eg. elderly, those prone to side effects. Target dose is 300mg BD if tolerated.
The same 24 hours dose can be given as 3 divided doses rather than 2 but this is more
costly. If Gabapentin is ineffective or side effects of Gabapentin cannot be tolerated,
consider Pregabalin instead of Gabapentin. Tricyclics may be given concurrently with
either Gabapentin or Pregabalin. Gabapentin and Pregabalin are not co-prescribed,
although there may be some overlap if Pregabalin is being introduced and dose is being
titrated upwards, whilst Gabapentin is being discontinued and dose is being titrated
downwards. Note – dose reduction required in renal impairment, avoid abrupt withdrawal
(withdraw over a minimum of one week), caution in severe congestive cardiac failure and
in conditions that may precipitate encephalopathy.
 Duloxetine
Note – this remains a black triangle drug as at November 2012, i.e. it is subject to intensive
monitoring by MHRA as a newly marketed drug. Prescribers should report any adverse
related effects via the yellow card system. Licensed for painful diabetic neuropathy and
approved in NHS Borders for neuropathic pain caused by non-diabetic neuropathy. Usual
starting dose 60mg, escalating to 90mg or 120mg based on clinical response.
Extract from Duloxetine (Cymbalta) ‘Summary of Product Characteristics’ / BNF 64:
Diabetic Peripheral Neuropathic Pain: The starting and recommended maintenance dose
is 60 mg daily with or without food. Dosages above 60 mg once daily, up to a maximum
dose of 120 mg per day administered in evenly divided doses, have been evaluated from
a safety perspective in clinical trials. The plasma concentration of duloxetine displays large
inter-individual variability. Hence, some patients that respond insufficiently to 60 mg may
benefit from a higher dose. Response to treatment should be evaluated after 2 months. In
patients with inadequate initial response, additional response after this time is unlikely so
discontinue. The therapeutic benefit should be reassessed regularly, at least every three
months
 Lidocaine 5% plaster
Approved for NHS Borders for patients with localised neuropathic pain, who may be
unable to tolerate oral analgesics.
Licensed for restricted use in treatment of neuropathic pain specifically associated with
post-herpetic neuralgia, when first line drugs approved for NHS Borders have been found
ineffective or for patients who have been intolerant of first line treatments.
Also approved for use in palliative care patients.
N.B. few side effects other than localised side effects with this plaster.
If very successful at controlling pain, these plasters may result in sedation in patients on
other sedative analgesics, i.e. sedation is not a side effect of lidocaine plasters per se.
Use 1 -3 plasters per day (has been added to NHS Borders Primary Care list of expensive
drugs)
 Opioids
Some forms of neuropathic pain may respond to opioids.
The British Pain Society provides useful information for the prescription of opioids for persistent nonmalignant pain on www.britishpainsociety.org/book_opioid_main.pdf
 Tramadol
Via its enhancement on the serotonergic and noradrenergic pathways, as well as the
opioid effect, Tramadol may be more helpful than other moderate-strength opioids at
reducing neuropathic pain.
Some patients may be susceptible to unpleasant psychogenic reactions e.g. agitation,
hallucinations, dysphoria, and elderly patients are susceptible to confusions and
hallucinations so tramadol should be avoided.
Avoid using tramadol if there is a history of epilepsy, acute head injury, impaired
conscious level because the risk of having seizures may be increased in these patients.
Caution is advised if used in conjunction with tricyclic antidepressants or SSRIs (risk of
serotonin syndrome). Do not give in combination with an MAOI antidepressant.
Avoid combined use with another opioid.
Potential for Misuse of Drugs prescribed for neuropathic pain
There have been reports of the drugs used to treat neuropathic pain being used
recreationally.
Recently Gabapentin and Pregabalin have become drugs of abuse. Tramadol is already
known to be used recreationally.
Prescribers should not issue repeat medications for these drugs unless there is clear
evidence of benefit for the patient in terms of symptom control, and in discussion with the
patient via a follow-up assessment and using prior knowledge of the patient in terms of
habits in relation to other drugs with abuse potential.
Appendix 1 :
S-LANSS
Below are 7 questions about your pain.
Think about how your pain has felt over the last week. Put a tick against the descriptions
that best match your pain. These descriptions may, or may not, match your pain no matter
how severe it feels.
Please only tick one answer for each question
1
2
3
4
5
6
7
In the area where you have pain, do you also
have ‘pins and needles’ tingling or prickling
sensations?
NO – I don’t get these sensations
YES – I get these sensations often
0
5
Does the painful area change colour (perhaps
looks mottled or more red) when the pain is
particularly bad?
NO – the pain does not affect the colour
of my skin
0
YES – I have noticed that the pain does
make my skin look different from normal
5
Does you pain make the affected skin abnormally
sensitive to touch? Getting unpleasant sensations
or pain when lightly stroking the skin might describe
this.
NO – the pain does not make my skin in
that area abnormally sensitive to touch
0
YES – my skin in that area is particularly
sensitive to touch
3
Does your pain come on suddenly and in bursts for
no apparent reason when you are completely still?
Words like ‘electric shocks’, jumping and bursting
might describe this.
NO – my pain doesn’t really feel like this
0
YES – I get these sensations often
2
NO – I don’t have burning pain
0
YES – I get burning pain often
1
In the area where you have pain, does your skin feel
unusually hot like a burning pain?
Gently rub the painful area with your index finger
and then rub a non-painful area (for example, an
area of skin further away or on the opposite side
from the painful area). How does this rubbing feel
in the painful are?
The painful area feels no different from the
non-painful area
0
I feel discomfort, like pins and needles,
tingling or burning in the painful area that is
different from the non-painful area
5
Gently press on the painful area with your
fingertip then gently press in the same way onto a
non-painful area (the same non-painful area that
you chose in the last question). How does this feel
in the painful area?
The painful area does not feel different
from the non-painful area
0
I feel numbness or tenderness in the painful
area that is different from the nun-painful
area
3
TOTAL SCORE =
> 12 = NEUROPATHIC PAIN see overleaf
S-LANSS Marking Guideline
1) Assign a mark to each question. For example: No for question 1 = 0, Yes = 5
1
0
5
2
0
5
3
0
3
4
0
2
5
0
1
6
0
5
7
0
3
2) Add up all the results
TOTAL =
3) If the total is over 12 then it is an indication that the pain is neuropathic in origin and
therefore they may respond to anti-neuropathic medications.
Appendix 2 : Referral Criteria for Chronic Pain Service
BORDERS RefHelp Information Template
Service
Who to refer
Who not to refer
How to refer
Borders Chronic Pain Service
.
 Pain present for >3 months
 Adults (16yrs or older)
 Pain causing significant distress/ disruption to life
 Patient accepting that a cure is not likely
 Able to attend/travel to appointments despite pain
 If predominantly musculoskeletal problem(esp. neck,
back problems), refer only after completion of
conventional physiotherapy or spinal specialist input
Referral guidelines on pain service intranet site
soon
 This is not primarily a diagnostic service and we
would expect a search for the underlying cause of
the pain to be undertaken prior to referral to pain
service. This may mean referral to appropriate specialty
(investigations and/or treatment also to be completed
beforehand).
 Awaiting outcome of referral to another service
 Inflammatory conditions (consider discussion with
rheumatology)
 Red flags – refer to appropriate specialty
 Conditions that would preclude ability to focus on selfmanagement approach eg.
- Significant active mental health problems
(including severe depression, suicidality,
psychosis, severe PTSD, personality disorder,
unresolved abuse/bereavement issues,
somatisation disorders). Alternative referral to
appropriate agency/service suggested.
- Chaotic alcohol/drug dependency behaviour
 Headache – exclude treatable pathology first (consider
referral to neurology).
 Re-referral – patients not to be referred for same pain
problem unless they are accepting of a pain selfmanagement approach
The pain
Location, duration, severity, underlying cause, temporal
variation, associated symptoms.
Previous management
Previous referrals, clinical findings, tests, treatment (and
outcomes of all of these), including previous pain clinic
input.
Current treatment
Medication, non-drug approaches, other management
including OT or physiotherapy, mental health input
Impact of pain
Sleep, mood, psychological problems, relationships,
function, work/caring role, social support
Past medical history
Including psychological and psychiatric history
Patient expectations
Discussion about reason for referral? yes/no
Self-management concept introduced to patient? yes/ no
Referrer expectations
Working diagnosis_____________________
Reason for referral (tick)
- medical (meds advice, intervention eg injection) □
- multi disciplinary self-management approach □
- other □
Alternatives to
Referral
Regarding suitability for referral to pain service, leave
message with secretary on 01896 826323 or
[email protected]
Voluntary services eg. Pain Association Scotland
(www.painassociation.com, freephone 0800 7836059)
Pain Concern (www.painconcern.org.uk, helpline 0300
1230789)
Resources
Chronic pain service website currently under
development.
Information leaflets available on www.bissy.scot.nhs.uk.
(Click on “information produced by NHS Borders” then
enter name into search field)
Other Info
Chronic pain service information leaflet –available as a
triple fold version of the information from the Chronic
Pain Service.
Appendix 3 : Chronic pain service information leaflet
INTRODUCTION
Your Doctor or Consultant has referred you to the NHS Borders Chronic Pain Service. You
most likely have ongoing pain that has lasted for at least 3 – 6 months and has not
responded to conventional treatments so far.
This leaflet aims to give you some information about the Chronic Pain Service. However, if
you would like further information you may contact the Pain Clinic secretary.
You will have many opportunities to ask questions when you come to see us. We are also
able to direct you to other sources of information as needed.
WHAT IS THE PAIN CLINIC?
We are a patient centred service which views each patient as an individual. We work with
patients on a one to one basis or in small groups.
We know that living with pain is not an easy thing to do. We also recognise that each
person’s pain is unique. Pain affects us in our day to day activities, our roles in life, our
relationships, our mood and our emotions.
A doctor who specialises in Pain Management will see you at your first appointment. Then,
if appropriate, they will organise appointments with the other team members. Each team
member will have key skills that they will bring to your care, although they may overlap at
times.
WHO ARE THE PAIN CLINIC TEAM MEMBERS?
Within the Pain Clinic Team there are 3 doctors who specialise in Pain Management.
The other team members are:





Clinical Nurse Specialist
Clinical Psychologist
Physiotherapist
Occupational Therapist
Team Secretary
WHAT WILL HAPPEN ON MY FIRST APPOINTMENT?
This appointment with a doctor will usually last approximately one hour and is usually in the
outpatients department, Borders General Hospital.
Prior to your initial appointment your doctor will review the questionnaire you have
completed and also review your medical history. This helps inform the doctor prior to your
appointment.
At this initial consultation you will be asked about your condition and then, if needed, you
may be examined with movements and tests.
Following this assessment, the doctor will discuss with you what they feel are the best
possible options for your condition and what our service has to offer you.
The doctor may provide you with some information leaflets to take home with you. Please
read these carefully.
CAN I BRING SOMEONE WITH ME?
Yes, if you wish to bring a relative or friend, please feel free to do so. If you wish this
person to be with you during any part of the assessment, you may ask him/her to join you.
WHAT SHOULD I WEAR?
Depending on your condition you may have to undress to your underwear, so the doctor
can complete a thorough assessment. It would therefore be helpful to wear clothing that
is easy for you to remove, or to bring a pair of shorts for back and lower limb problems. If
you feel uncomfortable about this please discuss with the doctor.
WHAT TYPES OF TREATMENT ARE AVAILABLE?
We do offer some ‘medical treatments’ such as medications, acupuncture, injections
and TENS machines. However, we find that these are best used alongside a self
management approach.
The predominant approach used in chronic pain clinics is a ‘self-management’
approach. This involves learning techniques, tools and strategies that can help you to
improve your quality of life whilst living with chronic pain. It may include relaxation
training, learning to pace your activities, improving your confidence and functional ability
and helping you to cope with difficult emotions.
WHAT IF I DON’T WANT TREATMENTS OFFERED?
Following assessment, the doctor will be able to make a treatment plan. They will discuss
with you what our service has to offer you and what they feel is the most appropriate
management for your condition.
You are not compelled to receive any assessment or treatment you do not want and
always have the right to refuse.
FOLLOW UP APPOINTMENTS
You may see various members of the Pain Clinic team; however, this will vary depending
on your needs.
You may also be asked to consider an intervention option and to contact the Pain Clinic
once you have made a decision. We ask that you do this within a 4 week period.
If you are expecting an appointment or further interventions and have not heard from the
Pain Clinic, we ask that you ring the secretary as soon as possible.
STUDENTS
NHS Borders is proud to be a training facility and sometimes students will accompany a
clinician. If you do not wish a student to be present please make this known to the
clinician.
CAN I CHANGE MY APPOINTMENT TIME?
It would be helpful if you keep your first appointment as arranged. If you are unable to
attend, please contact the secretary as soon as possible and they will try to arrange a
more suitable time.
WHAT HAPPENS IF I MISS AN APPOINTMENT?
If you are unable to attend either your first or a follow up appointment, please ring to
reschedule, giving at least 24 hours notice.
Please note that appointments cancelled at short notice or appointments missed add to
waiting times and may interrupt your treatment.
Should you fail to attend one appointment you will be sent a letter requesting you to
contact the Secretary to reschedule.
If we do not hear from you within 2 weeks, we can only assume that you no longer wish to
be seen and will discharge you back to the care of your doctor. This will also occur if you
miss more than 2 appointments with our service and we do not hear from you.
CANCELLATION OF APPOINTMENTS
If, due to unforeseen circumstances, your appointment needs to be cancelled every effort
will be made to contact you. If your contact details change it is important that you
contact the team secretary as soon as possible.
Appendix 4 : BISSY INFORMATION LEAFLETS ON NEUROPATHIC MEDICATIONS to follow on:
Tricyclics, Gabapentin, Pregabalin, Lidocaine 5% plaster, of direct relevance to the
primary care pathway and for interest for those referred to Chronic Pain Service : Ketamine,
Nabilone , non drug approaches and specific procedures used by the Chronic Pain Service